1) The patient is a 16-year-old female with a 2-year history of anorexia nervosa who was admitted to the hospital due to bradycardia and electrolyte abnormalities. 2) On admission, her weight was 40.3 kg (70.6% of ideal body weight) with a BMI of 14.65 kg/m2. She had been losing weight over the past year. 3) During her hospital course, she was started on a refeeding protocol of 1400 kcal/day to gradually increase to 3400 kcal/day. Her electrolytes were closely monitored for refeeding syndrome.

1. NUTRITIONAL MANAGEMENT OF
ANOREXIA NERVOSA
Anita Frankhauser
March 17, 2016
1
Preceptors:
Laura Bodine, MS, RD, CNSC, CD
Rachel Parks, MS, RD, CNSC, CSSD

2. OVERVIEW
Introduction
Research
History and Physical
Hospital Course
Application to Practice

3. Introduction
What is Anorexia Nervosa?
Anorexia nervosa is a serious, potentially
life-threatening eating disorder characterized
by self-starvation and excessive weight loss.
90-95% are women
0.5-1% of women are affected
https://www.nationaleatingdisorders.org/anorexia-nervosa
5-20% will die from disorder
Typically appears in early-mid adolescence

4. 4

5. 5

6. Introduction - Pathophysiology
Multi-causal
• Genetic
• Body dissatisfaction
• Adverse life event
• Difficulty with negative emotions
• Troubled relationships
https://www.nationaleatingdisorders.org/factors-may-contribute-eating-disorders

7. Introduction - Diagnosis
Diagnostic and Statistical Manual of Mental
Disorders DSM 5
A. Restriction of energy intake relative to
requirements
B. Intense fear of gaining weight or becoming fat
C. Disturbance in the way in which one’s body
weight or shape is experienced
D. Undue influence of body weight or shape on
self-evaluation, or denial of the seriousness of
the current low body weight
Mahan, L. Kathleen (2011-08-24). Krause's Food & the Nutrition Care Process (Food, Nutrition & Diet Therapy (Krause's)) (Page 490). Elsevier Health. Kindle Edition.

8. Introduction - Diagnosis
DSM 5
• Restricting Type
• Binge-eating, purging Type
Mahan, L. Kathleen (2011-08-24). Krause's Food & the Nutrition Care Process (Food, Nutrition & Diet Therapy (Krause's)) (Page 490). Elsevier Health. Kindle Edition.

9. Introduction - Diagnosis
DSM 5
• Severity
– Mild: BMI ≥ 17 kg/m2
– Moderate: BMI 16–16.99 kg/m2
– Severe: BMI 15–15.99 kg/m2
– Extreme: BMI < 15 kg/m2
Mahan, L. Kathleen (2011-08-24). Krause's Food & the Nutrition Care Process (Food, Nutrition & Diet Therapy (Krause's)) (Page 490). Elsevier Health. Kindle Edition.

10. Introduction - Signs and Symptoms
Pediatrics
•Failure to maintain normal
development trajectory
•Delayed puberty
Rosen DS. Identification and Management of Eating Disorders in Children and Adolescents. Pediatrics. 2010;126(6):1240–1253. doi:10.1542/peds.2010-2821
Diagnostic and Statistical Manual of Mental Disorders. American Psychiatric Association; 2013. doi:10.1176/appi.books.9780890425596..

11. Introduction - Signs and Symptoms
Bradycardia Hypothermia
Osteopenia,
osteoporosis
Muscle/fat
wasting
Weakness
Dry hair, skin;
hair loss; lanugo,
carotenemia
Rosen DS. Identification and Management of Eating Disorders in Children and Adolescents. Pediatrics. 2010;126(6):1240–1253. doi:10.1542/peds.2010-2821.
Diagnostic and Statistical Manual of Mental Disorders. American Psychiatric Association; 2013. doi:10.1176/appi.books.9780890425596.

12. 12
Introduction - Signs and Symptoms
https://www.urmc.rochester.edu/childrens-hospital/adolescent/eating-disorders/look-for.aspx

13. 13
Introduction - Signs and Symptoms

14. Introduction - Signs and Symptoms
food rules, excessive
chewing, moving food
around, excuses not to
eat, rigid exercise
regimen
esophagitis, GER,
vomiting, bloating,
abdominal pain,
constipation
stress, anxiety, OCD,
social withdrawal,
substance abuse,
suicide
amenorrhea, atrophic
breasts, atrophic
vaginitis
Rosen DS. Identification and Management of Eating Disorders in Children and Adolescents. Pediatrics. 2010;126(6):1240–1253. doi:10.1542/peds.2010-2821.
Diagnostic and Statistical Manual of Mental Disorders. American Psychiatric Association; 2013. doi:10.1176/appi.books.9780890425596.

15. Introduction – Treatment & Prognosis
Options
Inpatient vs. Outpatient
Maudsley Therapy
Day treatment
Pharmaceutical
15
Ozier AD, Henry BW. Position of the American Dietetic Association: nutrition intervention in the treatment of eating disorders. J Am Diet Assoc. 2011;111(8):1236-41.
Rosen DS. Identification and Management of Eating Disorders in Children and Adolescents. Pediatrics. 2010;126(6):1240–1253. doi:10.1542/peds.2010-2821.
Multi-disciplinary care
Medical
Psychology
Social work
Nutrition
Standard Treatment

16. Introduction – Treatment & Prognosis
Research
Repetitive transcranial
magnetic stimulation
(rTMS)
Telemedicine
16Ozier AD, Henry BW. Position of the American Dietetic Association: nutrition intervention in the treatment of eating disorders. J Am Diet Assoc. 2011;111(8):1236-41.
Van den eynde F, Guillaume S, Broadbent H, Campbell IC, Schmidt U. Repetitive transcranial magnetic stimulation in anorexia nervosa: a pilot study. Eur Psychiatry. 2013;28(2):98-101.
Alternative Treatments
Biofeedback
Acupuncture
Yoga
Stress management
Spirituality
Innovative Treatment

17. Repetitive transcranial magnetic
stimulation (rTMS)
Targeted magnetic pulses to induce neuronal activity
Noninvasive
FDA approved for depression
17
http://www.nimh.nih.gov/health/topics/brain-stimulation-therapies/brain-stimulation-therapies.shtml

18. Introduction – Treatment & Prognosis
18
Prognosis: ~50% achieve full recovery
Zipfel S, Löwe B, Reas DL, Deter HC, Herzog W. Long-term prognosis in anorexia nervosa: lessons from a 21-year follow-up study. Lancet (London, England). 2000;355(9205):721–2.

19. Introduction – Admission Criteria
AFCH Admission Criteria
Weight < 75% IBW (BMI < 15.99 in adults)
Rapid wt. loss
Arrested growth and development
Temperature Hypothermia (< 96 F or 35.6 C)
Cardiovascular HR < 50 bpm (day) or < 45 bpm (night)
decreases in SBP > 20 mmHg or DBP > 10 mmHg
or increase in HR > 20 bpm
Arrhythmia, chest pain
Lab Abnormal electrolytes, anemia
Malnutrition (BUN, Creat. , Alb, BG)
Females: FSH, LH, Prl, Urine beta-hcg
Additional
Symptoms
Acute medical complications e.g. seizures
Acute food refusal, uncontrolled binge-purge
Failure of outpatient therapy

20. Introduction – Refeeding Syndrome
#1
Nutrient repletion
Insulin secretion
#4
Arrhythmia
Heart failure
Death
#2 Increase intracellular
PO4, Mg 2+, thiamine,
K+, water
#3 Depletes serum
levels
Electrolyte
imbalance
Guarda AS, Redgrave G. Chapter 228. Eating Disorders. In: McKean SC, Ross JJ, Dressler DD,
Brotman DJ, Ginsberg JS. eds. Principles and Practice of Hospital Medicine. New York,
NY: McGraw-Hill; 2012.

21. History and Physical
SS: Demographic, social, prior medical history
• 16 year old Caucasian female, high school student,
tennis & soccer player
• Recently lost classmate in motor vehicle accident
• PMH: eating disorder 2 years ago after father diagnosed
with DM
Physical Exam and Review of Systems
Vitals
Diagnostic procedures

22. History and Physical
Physical Exam and Review of Systems
• General: awake, alert, no acute distress, appears
cachectic.
• Cardiovascular: bradycardic, normal S1 and S2, no
murmurs, gallops, or rubs, 2+ peripheral pulses, <2 second
capillary refill
• Extremities: cool and mottled appearing but with good
capillary refill, no cyanosis or clubbing, no deformities, no
edema

23. History and Physical
Physical Exam and Review of Systems
• Skin: no rashes or lesions noted, lanugo noted on arms
• NFPE: dark circles around her eyes, prominent clavicle,
square shoulders with bones prominent, and very little
muscle definition in her quads with prominent patella.

24. History and Physical
SS: Demographic, social, prior medical history
Physical Exam and Review of Systems
Vitals
• Bradycardia: sitting pulse 43, standing pulse 60
• BP: 100/69 mmHg
• Actual Weight: 40.279 kg (88 lb 12.8 oz)
• Height: 166 cm (5' 5.35")
• BMI (Calculated): 14.65 kg/m2
Diagnostic procedures: none

25. Introduction – Admission Criteria
✔
✔
✔
✔
70.6% IBW
sitting pulse 43,
standing pulse 60
BUN 22 H
Glucose 84 H
Magnesium 2.6 H
Inability to
maintain growth
trajectory
AFCH Admission Criteria
Weight < 75% IBW (BMI < 15.99 in adults)
Rapid wt. loss
Arrested growth and development
Temperature Hypothermia (< 96 F or 35.6 C)
Cardiovascular HR < 50 bpm (day) or < 45 bpm (night)
BP decreases in SBP >20 mmHg or Diastolic
BP > 20mmHg or increase in HR > 20 bpm
Arrhythmia, chest pain
Lab Abnormal electrolytes, anemia
Malnutrition (BUN, Creat. , Alb, BG)
Females: FSH, LH, Prl, Urine beta-hcg
Additional
Symptoms
Acute medical complications e.g. seizures
Acute food refusal, uncontrolled binge-purge
Failure of ambulatory/outpatient therapy

26. Hospital Course
Anthropometrics Nutrition History Intake
Physical
assessment
Diet type Lab Data
Medications
Nutrition
Diagnosis
Nutrition Assessment

27. Hospital Course
Anthropometrics
• Height: 166 cm (5' 5.35") (69%ile, Z = 0.65)
• Admission Weight: 40.279 kg (0.78 %ile, Z = -2.42)
• BMI-for-age: 14.62 kg/m2 (0.03 %ile, Z = -3.46)
• IBW: 57 kg (based on BMI-for-age at the 50th %ile) -
70.6% IBW
Total loss of 7.439 kg (15.6%) over ~1 year.

28. Hospital Course
Stature-for-age Percentiles

29. Hospital Course
Weight-for-age Percentiles

30. Hospital Course
BMI-for-age Percentiles

31. Hospital Course
Nutrition History
• Working with outpatient MD and RD to manage her
anorexia for 2 years.
• Interest in food increased
• Gradually restricted her intake to only “healthy” foods;
eliminated simple carbs, bread/cereals, fried foods,
butter/oils, desserts.

32. Hospital Course
Nutrition History
• Portion sizes decreased; only small bites of meals; very
small plates/bowls.
• Previous goal was 3000-3600 kcal/d and to eat 3 meals
with 3 snacks daily. She is not counting calories.

33. Hospital Course
Dietary intake, ~2-4 weeks PTA:
• Breakfast: yogurt, granola, OJ/AJ, and fruit
• AM Snack: Carnation Instant Breakfast with whole milk
(school days)
• Lunch: Peanut butter or hummus with crackers and
mixed vegetables or apples with peanut butter and
cheese. 8-10 oz Kefir shake and a granola bar on most
days (Kind, Lara, or Clif bars)
• PM Snack: handful of nuts

34. Hospital Course
Dietary intake, ~2-4 weeks PTA:
• Dinner: Last night had chicken, quinoa, broccoli, and
cheese casserole. 1/2-1 cup portion. 1 cup milk and a
side of fruit
• HS Snack: 1 can Ensure or Teddy Grahams with
applesauce or banana
• Fluids: Does not drink much water and did not recall a
fluid goal.

35. Hospital Course
Physical assessment
Chronic (>3 months), Severe Calorie-Protein Malnutrition
• Intake <25-50% of needs to support weight restoration
• BMI-for-age z-score of -3.46 with a change of 2.22 over 1
year.
• Total weight loss of 7.439 kg (15.6%) over 1 year
Bradycardia resting heart rate in 30-40's
Amenorrhea (LMP ~2 years PTA)

36. Hospital Course
Estimated needs based on 40.3 kg
• Initiate at 1400 kcal/day and gradually advance by 200 to
400 kcal/d to goal of 3400 kcal/day
• 1 to 2 g/kg/day protein
• 1900 to 2860 mL/day fluid - (1.0 - 1.5 x maintenance
fluids) using Holiday-Segar Method
Diet order: General, RS-2

37. Hospital Course – Lab Data
Day 1-3: every 12 hours to monitor for refeeding syndrome
Basic Chem
Magnesium
Phosphorus
GI/Liver
CBC
Anemia (B12 + Iron)
Urinalysis

38. Hospital Course – Lab Data
Day 1-3: every 12 hours to monitor for refeeding syndrome
Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7 Day 8 Day 9
Carbon
Dioxide
mmol/L 30 H 28 28 25 30 H 24 27 26 27
Anion Gap
mEq/L 7 6 L 6 L 9 6 L 9 7 7 8
BUN
mg/dL 22 H 20
Mg mg/dL 2.6 H 2.3 H 2.3 H 2.3 H 2.3 H 2.2 2.3 H 2.1 2.4 H
Phosphate
mg/dL 3.6 3.7 3.5 3.7 3.4 4 4.2 3.8 3.4
Protein,
total g/dL 3.9 L 6.5
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39. Hospital Course – Lab Data
Day 1-3: every 12 hours to monitor for refeeding syndrome
Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7 Day 8 Day 9
Carbon
Dioxide
mmol/L 30 H 28 28 25 30 H 24 27 26 27
Anion Gap
mEq/L 7 6 L 6 L 9 6 L 9 7 7 8
BUN
mg/dL 22 H 20
Mg mg/dL 2.6 H 2.3 H 2.3 H 2.3 H 2.3 H 2.2 2.3 H 2.1 2.4 H
Phosphate
mg/dL 3.6 3.7 3.5 3.7 3.4 4 4.2 3.8 3.4
Protein,
total g/dL 3.9 L 6.5
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40. Hospital Course – Lab Data
Day 1-3: every 12 hours to monitor for refeeding syndrome
Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7 Day 8 Day 9
Carbon
Dioxide
mmol/L 30 H 28 28 25 30 H 24 27 26 27
Anion Gap
mEq/L 7 6 L 6 L 9 6 L 9 7 7 8
BUN
mg/dL 22 H 20
Mg mg/dL 2.6 H 2.3 H 2.3 H 2.3 H 2.3 H 2.2 2.3 H 2.1 2.4 H
Phosphate
mg/dL 3.6 3.7 3.5 3.7 3.4 4 4.2 3.8 3.4
Protein,
total g/dL 3.9 L 6.5
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41. Hospital Course – Lab Data
Day 1-3: every 12 hours to monitor for refeeding syndrome
Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7 Day 8 Day 9
Carbon
Dioxide
mmol/L 30 H 28 28 25 30 H 24 27 26 27
Anion Gap
mEq/L 7 6 L 6 L 9 6 L 9 7 7 8
BUN
mg/dL 22 H 20
Mg mg/dL 2.6 H 2.3 H 2.3 H 2.3 H 2.3 H 2.2 2.3 H 2.1 2.4 H
Phosphate
mg/dL 3.6 3.7 3.5 3.7 3.4 4 4.2 3.8 3.4
Protein,
total g/dL 3.9 L 6.5
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42. Hospital Course – Lab Data
Day 1-3: every 12 hours to monitor for refeeding syndrome
Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7 Day 8 Day 9
Carbon
Dioxide
mmol/L 30 H 28 28 25 30 H 24 27 26 27
Anion Gap
mEq/L 7 6 L 6 L 9 6 L 9 7 7 8
BUN
mg/dL 22 H 20
Mg mg/dL 2.6 H 2.3 H 2.3 H 2.3 H 2.3 H 2.2 2.3 H 2.1 2.4 H
Phosphate
mg/dL 3.6 3.7 3.5 3.7 3.4 4 4.2 3.8 3.4
Protein,
total g/dL 3.9 L 6.5
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43. Hospital Course – Lab Data
Day 1-3: every 12 hours to monitor for refeeding syndrome
Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7 Day 8 Day 9
Carbon
Dioxide
mmol/L 30 H 28 28 25 30 H 24 27 26 27
Anion Gap
mEq/L 7 6 L 6 L 9 6 L 9 7 7 8
BUN
mg/dL 22 H 20
Mg mg/dL 2.6 H 2.3 H 2.3 H 2.3 H 2.3 H 2.2 2.3 H 2.1 2.4 H
Phosphate
mg/dL 3.6 3.7 3.5 3.7 3.4 4 4.2 3.8 3.4
Protein,
total g/dL 3.9 L 6.5
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44. Hospital Course - Medications
Medications
• Lidocaine
• PhosNaK (Neutraphos)
• Multivitamin
• Polyethylene glycol (Miralax)

45. Hospital Course
Nutritional Diagnosis: Malnutrition related to disordered
eating patterns with a history of anorexia nervosa as
evidenced by total weight loss of 15.6% over 1 year,
change in BMI-for-age Z-score of 2.22, bradycardia with
resting heart rate in the 40's and amenorrhea.

46. Hospital Course
Intervention: Eating Disorder Protocol
Monitoring/Evaluation: Calorie counts, labs,
anthropometrics, meal plan compliance, liberalization of
activity restrictions

48. Clinical Practice Guidelines
Treatment plan = Eating Disorder Protocol
• Admission Criteria
• Initial discussion – matter of fact, no bargaining, avoid trigger
words “calories or weight”, continuous supervision
• Health care team – meet within 24-48 hrs of admission, rounds
• Vital signs and monitoring – every 4-8 hrs, risk for refeeding
syndrome

49. Clinical Practice Guidelines
Treatment plan = Eating Disorder Protocol
• Activity Restriction
• Bed rest  sit up (bed, chair)  wheel chair  walk
• Constant supervision
• Fluids, meds – IVF, I/O q 4H, multivitamin, Miralax
• Lab tests – EKG, CBC, CMP, Mg, Phos, UA
• Meal planning – Initiate slowly, pt. identifies 3 likes, 3 dislikes
• Meal and snack procedures – 3 meals, 0-3 snacks, eat 100%
within 30 minutes

50. Hospital Course

51. Hospital Course

52. Hospital Course – Milestones
Day 1
•Initial Assessment, likes/dislikes, overview of treatment
•Initiate at 1400 kcal
•Physical Activity: none
•PhosNaK 2x/day
Day 2
•Goal: advanced to 1600 kcal, 3 meals + PM snack
•Physical Activity: none
•PhosNaK 2x/day
Day 3
•Goal: advanced to 1800 kcal, added AM snack
•Mg slightly elevated, Phos & K WNL
Day 4
•Goal: advanced to 2200 kcal
•Phos low  PhosNaK 3x/day
Day 5
•Goal: advanced to 2600 kcal
•Labs WNL

53. Hospital Course – Milestones
Day 6
•Goal: advanced to 3000 kcal
•Labs WNL
•Physical activity: 30 m in chair
Day 7
•Goal: remained at 3000 kcal
•Physical Activity: used wheel chair today
Day 8
•Reassessment
•Goal: advanced to 3400 kcal – goal met
•Physical activity: 1 lap around unit + wheelchair ride today
•Sitter during meals, video rest of time
Day 9
•Goal: 3400 kcal
•Labs WNL
•Physical activity: 2 laps around unit

54. Hospital Course – Milestones
Day 10
•Goal 3400 kcal
•Physical activity: 3 laps around unit
Day 11
•Goal 3400 kcal
•Physical Activity: 4 laps around unit, continued until DC
Day 12
•Goal 3400 kcal
•Sitter not needed, discontinued 24-hour supervision
•Discontinued daily labs
Day 13
•Discharge to Rogers Memorial Hospital: inpatient eating disorder
treatment for children and teens

55. Hospital Course - Milestones
40.279
39.826
39.463
39.735
40.189
40.733
41.731
41.4
41.7 41.912
42.638
43.092
42.4
35
37
39
41
43
45
1 2 3 4 5 6 7 8 9 10 11 12 13
Weight History (kg)
55

56. Hospital Course
Discharge planning and criteria
Required 72 hours prior to DC
• Resolution of orthostatic symptoms
• HR > 40 for 24 hours
• Stable labs
• Disposition (inpatient vs outpatient)
• Weight stabilization or weight > 75%
IBW
Appointments with PCP, Outpatient RD,
Eating disorder MD, Behavioral Health
Day 12
• HR: 64 bpm
• Resp: 16 breaths per min.
• BP: 103/57 mmHg
• Temp: 36.8 ºC (98.3 ºF)
• Weight: 43.092 kg (95 lb)
75.6% IBW

57. Hospital Course
Patient outcome
• Discharge to inpatient eating disorder facility
• Continue 3400 kcal meal plan per eating disorder
protocol.
• Continue collaboration with outpatient PCP and
behavioral health

58. Application to Practice
Signs of disordered eating
• Diet mentality
• Strict food “rules”
• Compensatory behaviors
Communicate with health care team
Request referrals to behavioral health
Resources…learn more
• Academy Position Statement
• Life Without Ed by Jenni Schaefer
• Intuitive Eating by Eveleyn Tribole, RD and Elyse Resch
RD

59. Thank you
59

60. References
60
1. National Eating Disorders Association: Anorexia Nervosa. https://www.nationaleatingdisorders.org/anorexia-nervosa.
Accessed March 1, 2016.
2. Mahan, L. Kathleen (2011-08-24). Krause's Food & the Nutrition Care Process (Food, Nutrition & Diet Therapy
(Krause's)) (Page 490). Elsevier Health. Kindle Edition.
3. Rosen DS. Identification and Management of Eating Disorders in Children and Adolescents. Pediatrics.
2010;126(6):1240–1253. doi:10.1542/peds.2010-2821.
4. Diagnostic and Statistical Manual of Mental Disorders. American Psychiatric Association; 2013.
doi:10.1176/appi.books.9780890425596.
5. Ozier AD, Henry BW. Position of the American Dietetic Association: nutrition intervention in the treatment of eating
disorders. J Am Diet Assoc. 2011;111(8):1236-41.
6. Van den eynde F, Guillaume S, Broadbent H, Campbell IC, Schmidt U. Repetitive transcranial magnetic stimulation
in anorexia nervosa: a pilot study. Eur Psychiatry. 2013;28(2):98-101.
7. Zipfel S, Löwe B, Reas DL, Deter HC, Herzog W. Long-term prognosis in anorexia nervosa: lessons from a 21-year
follow-up study. Lancet (London, England). 2000;355(9205):721–2.
8. Guarda AS, Redgrave G. Chapter 228. Eating Disorders. In: McKean SC, Ross JJ, Dressler DD, Brotman DJ,
Ginsberg JS. eds. Principles and Practice of Hospital Medicine. New York, NY: McGraw-Hill; 2012.
http://accessmedicine.mhmedical.com.ezproxy.library.wisc.edu/content.aspx?bookid=496&Sectionid=41304219.
Accessed March 11, 2016.
9. Heimburger DC. Malnutrition and Nutritional Assessment. In: Kasper D, Fauci A, Hauser S, Longo D, Jameson J,
Loscalzo J. eds. Harrison's Principles of Internal Medicine, 19e. New York, NY: McGraw-Hill; 2015.
http://accessmedicine.mhmedical.com.ezproxy.library.wisc.edu/content.aspx?bookid=1130&Sectionid=63653604.
Accessed March 11, 2016.