Puneet Khokhar
Case Study 1: Anorexia Nervosa and Bulimia Nervosa
I.
Understanding the Disease and Pathophysiology
a. Describe the diagnostic criteria for anorexia nervosa (AN), bulimia nervosa (BN), and
binge eating disorder (BED). Include all types (binging/purging AN, restrictive AN,
purging BN, non-purging BN), and discuss which type of eating disorder you believe Paris
presents with. Provide examples to support your rationale.
i. Anorexia nervosa:
1. Refusal to maintain body weight at or above a minimally normal weight
for age and height (e.g. weight loss leading to maintenance of body
weight less than 85% of that expected; or failure to make expected
weight gain during period of growth, leading to body weight less than
85% of that expected)
2. Intense fear of gaining weight or becoming fat, even though
underweight
3. Disturbance in the way in which one’s body weight or shape is
experienced, undue influence of body weight or shape on selfevaluation, or denial of the seriousness of the current low body weight.
4. In postmenarcheal females, amenorrhea (i.e. the absence of at least
three consecutive menstrual cycles)
a. Restricting type: during the current episode of AN, the person
has not regularly engaged in binge eating or purging behavior
b. Binge eating/purging type: during the current episode of AN,
the person has regularly engaged in binge eating and purging
behavior.
ii. Bulimia nervosa:
1. Recurrent episodes of binge eating. An episode of binge eating is
characterized by both of the following:
a. Eating, in a discrete period of time (e.g. within any 2-hour
period), an amount of food that is definitely larger than most
people would eat during a similar period of time and under
similar circumstances
b. A sense of lack of control over eating during the episode (e.g., a
feeling that one cannot stop eating or control what or how
much one is eating)
2. Recurrent inappropriate compensatory behavior to prevent weight gain,
such as self-induced vomiting; misuse of laxatives, diuretics, enemas, or
other medications; fasting; or excessive exercise
3. The binge eating and inappropriate compensatory behaviors both occur,
on average, at least twice a week for 3 months
4. Self-evaluation is unduly influenced by body shape and weight.
5. The disturbance does not occur exclusively during episodes of AN.
a. Purging type: during the current episode of BN, the person has
regularly engaged in self-induced vomiting or the misuse of
laxatives, diuretics, or enemas.
b. Nonpurging type: during the current episode of BN, the person
has used other inappropriate compensatory behaviors such as
fasting or excessive exercise but has not regularly engaged in
self-induced vomiting or the misuse of laxatives, diuretics, or
enemas.
iii. Binge eating disorder:
1. Recurrent episodes of binge eating in the absence of the regular use of
inappropriate compensatory behaviors characteristic of BN.
2. Binge episodes must occur at least 2 days per week for a period of 6
months.
iv. Paris: Anorexia Nervosa with binging and purging tendencies
1. Anorexia nervosa:
a. Underweight
b. Hasn’t had a menstrual cycle in 2 years
c. Malnourished
i. Vitamin deficient (as evident by vit. C def. symptoms)
ii. Protein deficient (as evident by low albumin levels, and
low bp)
2. Binging /Purging tendencies:
a. Abrasions seen on back of throat
b. History of excessive exercise
b. Describe the common psychological, socioeconomic, and environmental characteristics
of an individual with AN.
i. Psychological features of AN include a preoccupation with perfectionism,
compulsivity, harm avoidance, feelings of ineffectiveness, inflexible thinking,
overly restricted emotion expression, and limited social spontaneity.
Psychological co-morbidities may also exist such as depression, dysthymia,
anxiety disorders, obsessive compulsive disorder, personality disorders, and
substance abuse.
ii. The prevalence of AN is mostly in westernized and industrialized nations. Its
initial presentation is usually in adolescence, or early adulthood. New cases that
appear in later adult hood may be due to the stress of adverse life events.
iii. High stress situations appear to trigger AN behavior in those who have had a
remitting course, and cause new cases of AN.
1. Sexual or physical abuse
2. Family discord
3. High stress/pressure occupation
c. What does research indicate about the possible roles of genetics in eating disorders?
i. Research seems to indicate that there is a genetic predisposition to developing
AN with the gene located on chromosome 1p.
d. How does being eating disorder differ from BN?
i. It also features binge eating, but it has an absence of a compensatory behavior
(purging, exercise, etc.)
e. What is the long-term prognosis for AN, BN, and BED?
i. AN: Five to twenty percent of patients with anorexia nervosa die from AN, half
of those with AN die from other medical complications associated with the
disease. Those who go on with the disease suffer from malnutrition,
dehydration, electrolyte imbalances, that can also trigger cardiac arrhythmias
and cardiac failure. Although there is no medication for AN specifically, other
psychiatric medications can help with comorbitities that may trigger behavior
(anxiety, depression, etc.). It is estimated that about 20% of those with AN
suffer chronically from its symptoms.
ii. BN: It is often a remitting/relapsing course.
f. Describe the medical consequences associated with AN, BN, and BED.
i. AN:
1. Electrolyte imabalance, cardiac arrhythmias, sudden heart failure.
2. Low blood pressure, low levels of protein, decreased immune function
3. Glucose insensitivity
4. Hormonal imbalance due to low body weight (thyroid dysfunction,
menstrual irregularities)
5. Increased levels of cholesterol and carotenemustcle wasting, diminished
DTRs
6. Osteoporosis
7. Dry skin, edema, hypothermia, lenugo, dry brittle hair
8. Dizziness, confusion
ii. BN:
1. Esophageal tears/strictures from purging
2. Esophagitis
3. Enamel erosion, calluses on hands
4. Decreased potassium levels, increased CO2, and increase amylase
5. Diarrhea, edema
6. Parotid gland enlargement
iii. BED:
1. Increased weight gain, leading to problems associated with
overweight/obesity pathology (metabolic syndrome)
g. Define starvation, binge eating, and purging.
i. Starvation:
1. A severe deficiency in caloric energy, nutrient intake, and vitamin
intake.
II.
ii. Binge eating: an episode of eating marked by three particular features
1. The amount of food eaten is larger than most persons would eat under
similar circumstances
2. The excessive eating occurs in a discrete period, usually less than 2
hours
3. The eating is accompanied by a subjective sense of loss of control
iii. Purging:
1. Methods intended to reverse the effects of binge eating: self induced
vomiting, laxative use, enemas, and diuretic use.
h. Describe the metabolic response to voluntary starvation. Compare Paris’s signs and
symptoms to the metabolic response to starvation.
i. The body’s glycogen stores are used up in about 24 hours, and then energy is
produced through lipolysis. This is evident because she is severely underweight,
and her body is using her fat stores as energy.
i. To be successful, treatment of eating disorders must include a team approach among
physicians, registered dieticians, and psychologists. Describe the role of each in
treatment.
i. Physicians are needed to prescribe medications to deal with associated mental
health issues.
ii. Registered dieticians are necessary to provide proper counseling on diet, and
meal planning.
iii. Psychologists are necessary to provide cognitive behavioral therapy, and
psychotherapy to overcome emotional issues.
j. Why might it be necessary to include a psychiatrist as a member of the treatment team?
i. To prescribe medications to address the associated mental health issues that
can trigger and exasperate the AN behavior (anxiety, depression, etc.).
Understanding the Nutrition Therapy
a. Briefly, what are the primary nutrition therapy goals for acute diagnosis of AN? How will
these goals change as treatment progresses?
i. Correct biological and psychological sequelae of malnutrition, restore body
weight, normalize eating patterns, normalize hunger/satiety cues
ii. Hospitalize when patient is medically unstable, severely malnourished, or
growth retarded.
iii. Institutional protocols: patient participation in menu planning and meal
planning approaches
iv. Weight gain: 2-3 pounds per week for inpatients, and 0.5-1 pound per week
outpatient.
v. As the patient progresses, 200-300 calories should be added per day.
b. What are the primary nutrition therapy goals for BN?
i. Caloric prescription for weight maintenance
1. Provide 1500 to 1600 kcal/day diet if patient is hypometabolic
2. Provide DRI for energy if metabolic rate is normal
III.
3. Monitor body weight and adjust caloric prescription for weight
maintenance
4. Avoid weight reduction diets until eating patterns and body weight are
stabilized
ii. Macronutrients
1. Protein
a. Minimum intake = RDA in g/kg ideal body weight
b. 15% to 20% kcal
c. High biologic value sources
2. Carbohydrate
a. 50% to 555 kcal
b. Encourage insoluble fiber for treatment of constipation
3. Fat
a. 25% to 30% kcal
b. Provide source of essential fatty acids
iii. Micronutrients
1. 100% RDA multivitamin with minerals supplement
2. Note that iron-containing preparation may aggravate constipation
c. What are the primary nutrition therapy goals for BED?
i. Nutrition counseling and dietary management
ii. Individual and group psychotherapy
iii. Medication
iv. Goals: self-acceptance, improved body image, increased physical activity, better
overall nutrition
d. Describe prevention strategies that could reduce a person’s risk of developing AN, BN,
or BED.
i. Eating disorders can be prevented by addressing the emotional, psychological,
social, and physical issues behind it. Encouraging healthy, realistic attitudes
toward weight and diet. Support groups, and talk therapy.
Nutrition Assessment
a. Evaluation of weight/body composition
i. What are the typical differences in body weight between someone with AN and
someone with BN?
1. AN patients are generally under 85% of their expected body weight.
2. BN patients are generally slightly overweight, or normal in weight.
ii. Calculate and interpret Paris’s BMI.
1. 52.2727/(1.72)² = 17.67
2. A normal body weight for someone her height would be 140, so she is
around 82% of the normal body weight of someone of her height
iii. What would be an appropriate weight for her in 1 month? In 3 months? In one
year? Describe the rationale for choosing the weight values you did.
1. If she is inpatient, she should be gaining about 2-3 pounds per week,
and according to her height she should be 140 pounds
a. 1 month: 125 pounds
b. 3 months: 140 pounds
c. 1 year: 140pounds
2. If she is outpatient, she should be gaining about 0.5-1 pound per week
a. 1 month: 118 pounds
b. 3 months: 124 pounds
c. 1 year: 140 pounds
b. Calculation of nutrient requirements
i. Calculate the outpatient treatment energy requirements for Paris.
1. Her goal should be to gain 0.5-1 pound per week. Calorie prescriptions
of 1000 to 1600 kcal/day will initiate weight gain.
c. Intake domain
i. Using her 24 hour recall, calculate this patient’s current energy and protein
intake = 132 calories per day, 2.5g protein per day
1. Orange juice (4 oz)
a. 52 calories
b. 0g protein
2. Coffee (4 cups)
a. 32 calories
b. 0g protein
3. Whole wheat bagel (1/4)
a. 36 calories
b. 1.5g protein
4. Diet coke (24 oz)
a. 0 calories
b. 0g protein
5. Peas (6)
a. <12 calories
b. < 1g protein
ii. List any nutrition problems within the intake domain using the appropriate
diagnostic term
1. Inadequate energy intake: NI-1.4
2. Inadequate oral food intake: NI-2.1
3. Inadequate protein-energy intake: NI-5.3
4. Inadequate fat intake: NI-5.6.1
5. Inadequate protein intake: NI-5.7.1
6. Inadequate carbohydrate intake: NI-5.8.1
7. Inadequate fiber intake NI-5.8.6
8. Inadequate vitamin intake: NI-5.92
9. Inadequate mineral intake: NI-5.10.1
10. Altered nutrition-related laboratory values: NC-2.2
11. Underweight NC-3.1
12. Harmful beliefs/attitudes towards food: NC-1.2
d. Clinical domain
i. Evaluate Paris’s lab results
1. Paris’s lab results indicate that her total protein is low, and her albumin
levels are low. Her sodium levels are high, her potassium levels are low,
and her magnesium levels are low, indicating electrolyte imbalance.
Her glucose levels are high, indicating insulin insensitivity. Her
hematologic values are abnormal as well, indicating decreased immune
function and decrease in types of cells. Her alkaline phosphatase levels
are high indicating stress.
ii. During nutritional repletion, Paris should be monitored closely for refeeding
syndrome. What are the characteristics of refeeding syndrome?
1. Refeeding syndrome is a potentially lethal complication of providing
nutritients to someone in the anabolic state, that is due to electrolyte
fluctuations that can cause metabolic, hemodynamic, and
neuromuscular problems. The hallmark of this syndrome is low serum
levels of potassium, phosphorus, and magnesium. Reintroducing food,
especially carbohydrates, can cause a shift of the electrolytes into the
intracellular space and glucose moves into the cells. The patient is also
at risk from cardiac and pulmonary complications due to fluid overload,
because when there is a spike in insulin, the excretion of salt and water
reduces. It is important to monitor patients, and supplement them with
phosphorus, potassium, and magnesium.
iii. Why was the EKG ordered?
1. The EKG was ordered because some of her electrolytes were out of
balance, and her blood pressure and HR are low. It is important to
assess the cardiac status of patients with AN because their severe
nutrient restriction may be altering their body chemistry, which can
cause arrhythmias and heart failure.
e. Behavioral-Environmental Domain
i. Identify a minimum of five questions that the dietician would ask regarding
Paris’s purging behaviors.
1. How many laxatives do you take, and how often?
2. What kind of laxatives do you take?
3. How often do you exercise? For how long?
4. What exercises do you do?
5. How often do you purge (vomit)?
6. Have you noticed a trigger situation that causes you to purge?
ii. Paris asks you for a list of “good” foods to eat and “bad’ foods to avoid. What
should you tell her?
IV.
V.
VI.
1. Biased nutrition counseling (good vs. bad) would be in direct conflict of
what her treatment plan would be. It is especially important in treating
AN patients that you help remove the mental bias and conflict over
food. Biased language must be avoided, and literate that is provided
needs to be checked to make sure it is not inappropriate.
iii. From the information gathered, list possible nutrition problems with the
behavioral-environmental domain using the appropriate diagnostic term.
1. Harmful beliefs/attitudes towards food: NC-1.2
Nutrition Diagnosis
a. Select two high-priority nutrition problems and complete PES statements for each.
i. Inadequate protein intake due to her restricted diet, as evidence by low serum
levels of protein and albumin and diet history.
ii. Inadequate oral food intake due to restricted diet as evident by her BMI of
17.67.
Nutrition Intervention
a. For each PES statement written, establish an ideal goal (based on signs and symptoms
and an appropriate intervention (based on etiology).
i. Provide appropriate counseling on the importance of protein consumption, and
begin consumption of protein by introducing one protein rich item per meal.
ii. Provide appropriate counseling on the importance of food and nutrient
consumption, and increase the amount of nutrient rich foods per meal.
Nutrition Monitoring and Evaluation
a. When should you schedule your next counseling session with Paris?
i. I believe she should be hospitalized until her electrolytes are back in balance. If
she does not want inpatient treatment after she is medically stable, she will still
need several hours of counseling per day, several times per week until she is
able to adequately nourish herself at least to the point of maintaining normal
labs.
b. What parameters can be used to measure Paris’s response to treatment?
i. She can have her blood work redone to assess if her body is still under stress,
and still severely deficient in nutrients. Her weight can be measured every
week, to determine if the prescribed protocol is effective.
c. What would you assess at this follow-up counseling?
i. I would assess her feelings and her outlook on the treatment plan. I would want
to know how she feels about the changes that she is trying to make, and if she
feels like she can do them. I would also see how her intake was going, and if she
was able to gain weight based on the changes that she was told to carry out,
and if she wasn’t, to help pick foods that she felt that she may actually be able
to consume, and successfully gain weight with.
d. What medical conditions warrant residential or inpatient treatment?
i. Electrolyte imbalances are very important to correct, because they could
precipitate cardiac arrhythmias and sudden heart failure. It is also important to
correct the patient’s glucose levels, and blood pressure (low bp).