Case Study:

Anorexia Nervosa

Rob Fancher
NUTR4630 Adv. Medical Nutrition Therapy
Section: HA
Prof. Emily LaRose
4/22/16
 Anorexia Nervosa

22yo F admitted earlier today with a new dx of AN (restricting type); hypotension, bradycardia,
and dehydration. PMH includes mild anxiety, no hx of ED; wisdom teeth removal at 17 yo, UTI 1-
2x/yr over the past 3 years or so.

Anthros: Ht: 67 Wt: 99# Wt at last MD visit (4 mos ago): 133#

Admission Labs: Na 147mEq/L, K 3.2mEq/L, BUN 30mg/dL, Cr 0.8mg/dL, Phos 2.4mg/dL, Mg

1.9mEq/L, Prealb 19mg/dL, Glucose 64mg/dL, H/H 10.8g/dL/27%, CRP 1.1mg/L

Vitals: BP 92/56, HR 45-52, O2 Sat 96%; Q 4 hr vitals for now

Physical Exam: very thin appearing young woman, pale; thin, dry skin and hair. Minimal
adiposity evident around eyes; visible ribs. Lanugo evident on arms. Limited calf muscle, thin
quads; visible clavicle, minimal subQ fat on triceps.

Meds: none; awaiting psych eval

Diet: IVFs D5NS @ 80ml/hr for now

ED Protocol- Meals per RD Meal Plan

Intake PTA (Usual Intake):

Breakfast: 8ozs black coffee (made with tap water), 2 ozs skim milk, 2 packets Equal,
cup fresh blueberries, 1 cup Fiber One cereal (dry), 16 ozs water
Lunch: 2 cups shredded romaine lettuce, 12 Fat Free Caesar Croutons, cup cucumber
(peeled and sliced), 1 tbsp chickpeas (canned), a pinch of crushed red pepper (0.1 tsp), 1
wedge of lemon (juice only), 5 dry-roasted & salted almonds, 1 container of fat free
vanilla pudding (3.5ozs, ready to eat), 20 ozs Crystal Light lemonade (sugar free), 25 ozs
water
Snack: Coffee (black- made with tap water), 2 packets Equal, 1 large bell pepper (sliced)
Dinner: 4 ozs roasted salmon, cup spinach (cooked, drained) with black pepper (0.2
tsp) & salt (0.1 tsp), tsp olive oil, 16 ozs water
Snack: cup raspberries, cup lemon sorbet (fat-free, Haagen Das)

Nutrient Needs:
Energy: Initial goal: you determine and justify
Final Goal: you determine and justify
Protein: You determine and justify
Fluid: Holliday Segar
Patient Interview: Pt reports that she moved to RI from Florida for work about 7 mos ago, and
she has had a difficult time adjusting. Lives alone and reports that her family and friends are all
back home; has no real support system locally except for an aunt about 2 hrs away. She works
about 60 hrs/wk so she feels she doesnt have a lot of time to cook; will eat packaged foods or
get something prepared from Whole Foods on her way home from work. Joined a running
group; generally runs 4-6 miles 3-4 days/wk, will go to spinning or swim once/wk, and goes to
yoga on Sunday mornings. Denies any current concerns about her wt; reports that she feels
good at her current wt and said she was kind of chubby before. Does not want to gain weight
at this time. Has always had irregular periods so was put on birth control about 3 yrs ago.
Does not use any supplements, diuretics, or laxatives; denies purging and states she has always
been active, no recent changes in activity. + FHx of depression, anxiety. Personal hx of anxiety
has been intermittent x 5 yrs. No hx of diarrhea; some constipation reported.

Diet Notes (from interview): Follows a pescatarian diet though is open to including poultry.
Likes fish, veggies, most fruits, plain cereals, almonds, hard boiled eggs, Mexican food; dislikes
fried foods, sushi, ice cream, cheese, peanuts, dried fruits. Avoids most bread, rice, potatoes,
pasta, sugar, honey because of carb content; will sometimes eat corn. She is asking how many
kcals and how much fat you plan to give her.

Notes:
Pt has been put on Eating Disorder Protocol to include 1:1 supervision of meals (a PCA
will do this) and daily meal planning with the RD.
o You will use std protocol exchanges for meals/snacks refused.
o EACH DAY you will have to plan ALL of her meals (3) and snacks (3) with her to
meet specific kcal, protein, and fat goals (using appropriate macronutrient
distribution).
o You and the patient will collaborate on what she will receive- though you MUST
meet all of your nutritional goals.
Usual intake record MUST be fully analyzed in ESHA with results for all macronutrients,
fluids, etc. included in your medical record documentation.
Energy needs must include an initial goal (with rationale) and a final goal. In your
recs/interventions, you will include a plan for advancement as well (though you will see
her DAILY so it wont happen automatically).
SOAP/ADIME Hybrid Form

Interval History: 22 YOF admitted for new dx of AN (restricting type), hypotension,

bradycardia, and dehydration.

Anthropometrics:
Ht: 67 IBW: 135 lbs
% IBW: 73.3%
Ht (cm): 170.2 cm IBW (kg): 61.4 kg
Admit Wt: 99 lbs UBW: 133 lbs
% UBW: 74.4%
Admit Wt (kg): 45kg UBW (kg): 60.5 kg
Current Wt: 99 lbs BMI: 15.5
AIBW (for obesity): N/A
Current Wt (kg): 45 kg BMI Class: Underweight
Est. Dry Wt: N/A
Wt Hx: 133 lbs at last MD visit (4 mos ago) (25.6% wt loss)
Est Dry Wt (kg): N/A

Labs: Na 147mEq/L, K 3.2mEq/L, BUN 30mg/dL, Cr 0.8mg/dL, Phos 2.4mg/dL,

Mg 1.9mEq/L, Prealb 19mg/dL, Glu 64mg/dL, H/H 10.8g/dL/27%, CRP 1.1mg/L

Vitals: BP 92/56, HR 45-52, O2 Sat 96%; Q 4 hr vitals for now

Current Meds: None; awaiting psych eval

Diet: IVFs D5NS @ 80ml/hr for now; ED Protocol Meals per RD meal plan

Nutrition Needs/Intake:
Est. energy needs determined below to begin slightly higher than pt previous intake to
promote wt gain but prevent refeeding syndrome. Final goal est. energy needs determined
by following MNT guidelines for AN weight maintenance (Krause), then setting an
appropriate kcal/kg range based on BEE and accounting for pts high activity level. Protein
needs determined by following refeeding guidelines of 20-30% est. energy needs, then
defining appropriate g/kg.
Wt: 45kg Est. Needs Previous Intake % Goal Met
Initial: 1000 kcal/d
Goal: 3150 kcal/d (70 kcal/kg/d
85.8% (based
late treatment wt gain phase)
Calories 858 kcal on initial est
Final Goal: 2025-2250 kcal/d
needs)
(45-50 kcal/kg/d wt
maintenance phase

67.5-72 ~69.3%
Protein 48.4g (based on
(1.5-1.6 g/kg/d)
est. 69.8g)

Fluid
Using Holliday- 2328 ml/d 3001 ml 128.9%
Segar

Assessment: Young woman appearing very thin and pale, ribs visible; thin, dry skin and
hair; Shows signs of subQ fat loss in orbital region; Lanugo apparent on arms; limited calf
muscle and thin quads; clavicle visible; minimal subQ fat on triceps.
Anthros: Pt has lost 25.6% body wt (34 lbs) over 4 mos. Pt is currently 73.3% IBW and has an
underweight BMI of 15.5

Patient Interview: Pt reports that she lives alone in RI, family lives in FL; has had difficulty
adjusting to the move, closest family 2 hours away. Usually eats packaged/prepared foods
due to working ~60hrs/wk. Pt is very active, runs with a group 4-6 miles, 3-4 days/wk, goes
to classes at gym 1x/wk and yoga 1x/wk. Pt denies purging, laxative/diuretic/supplement
use, and states no concern over current wt. Says she has always been active, and feels good
at current wt. Pt has hx of anxiety occurring over the past 5 years. No hx of diarrhea, but
some hx of constipation. She avoids high carb foods such as bread, rice, pasta, potatoes;
follows a pescatarian diet but is open to including poultry.

Intake PTA: Pts intake is restricted and is notable for avoidance of dietary fat, use of artificial
sweeteners, diuretics (coffee)
Breakfast: 8oz coffee, 2oz skim milk, 2 packets Equal, 1/4 cup blueberries, 1 cup Fiber One
cereal, 16oz water
Lunch: 2 cups shredded romaine lettuce, 12 fat-free Caesar croutons, cup cucumber, 1
tbsp chickpeas, juice of 1 lemon wedge, 5 almonds, 3.5oz container fat-free pudding, 20oz
sugar-free Crystal Light lemonade, 25oz water
Snack: 8oz coffee, 2 packets Equal, 1 large bell pepper
Dinner: 4oz salmon, cup spinach cooked in tsp olive oil, 16oz water
Snack: cup raspberries, cup Haagen Das fat-free lemon sorbet

Labs: Na high d/t dehydration; K low d/t malnutrition; BUN high d/t dehydration; Glu low
d/t lack of precursors for gluconeogenesis caused by low bw and severe malnourishment;
H/H low d/t loss of lean body mass (lower RBC count)

Vitals: BP low (hypotension), HR low (bradycardia) d/t severe malnourishment and low bw

Nutrition Diagnosis:
o Chronic, severe, starvation-related malnutrition r/t AN (restricting type) AEB 25.6%
wt loss x 4 mos, physical assessment notable for fat loss (orbital region, triceps,
ribs), muscle loss (calf, quads), and lanugo, BMI 15.5
o Altered nutrition-related laboratory values (H/H) r/t AN (restricting type), loss of
lean body mass AEB Low H/H value 10.8g/dL/27%
o Inadequate fat intake r/t avoidance of dietary fat AEB 24 hr recall notable for 17.2%
total energy from fat, prepared food products remarkable for being fat-free
o Disordered eating pattern r/t restrictive eating habits AEB 25.6% wt loss x 4 mos, 24
hr recall notable for meeting 85.8% est. energy needs.
Goals:
o Pt will consume 100% of meals with supervision
o Prevent refeeding syndrome
o Restoration of healthful weight followed by maintenance of weight
o Controlled wt gain of 1-2 lbs/wk once caloric goal is met
o Improvement in eating attitudes and behaviors/patterns by providing diet education
during hospitalization
o Establish healthy body image through cognitive behavioral therapy
Interventions/Recommendations:
1. Rec daily meal planning with pt and RD; 3 meals and 3 snacks daily - ~250kcal/meal
and 75kcal/snack
Pt will require 1:1 supervision, restricted from using restroom during meal
time as per ED Protocol
No non-caloric beverages, no fat-free or sugar free products
If pt refuses to consume 100% of meal in 30 min, supplement Boost (flavor
per pt preference) for remaining calories
If pt refuses to consume remaining calories via PO Boost within 30 minutes,
insert NG tube and give remaining calories via gravity.
2. RD will meet with pt daily to plan meals and increase calorie intake ~100-200kcal/d
until caloric goal is met
3. Rec thiamine supplement PO 200mg/d x 10d
4. Rec daily oral supplementation of multivitamin (Centrum Women, 1 tablet qd with
food), B complex (Nature Made B Complex, 1 caplet qd with food)
5. Rec check Fe panel with next labs (TIBC, Iron, %Sat, Ferritin), CRP to further evaluate
low H/H
6. Rec check Ca with next labs to evaluate risk of osteopenia/osteoporosis
7. Rec monitor K, Phos, Mg daily over the next 10 days for refeeding syndrome
8. Encouraged pt to choose HBV protein sources(fish, poultry, eggs) during meal
planning
9. Encouraged pt to choose sweeteners that provide calories (sugar, honey, agave),
and discouraged use of artificial, non-caloric sweeteners (Equal)
10. Discussed balanced eating, food myths (fat is bad), discouraged labeling of food as
bad or good

Plan: Daily meal planning with RD, 1:1 supervision at meal times, diet education

Anticipated D/C Needs: TBD

Nutrition Student ref200@jwu.edu

Diet Recall ESHA Analysis

Spreadsheet Usual Intake

Bar Graph Usual Intake
Calories & Fats Pie Chart Usual Intake