Anorexia nervosa

Question 1

What is the definition of anorexia nervosa?

Answer 1

A psychiatric condition characterized by restriction of food intake in what has been termed the “relentless pursuit of thinness.”
Predmoninatly observed in girls and young women.
Males represent 5-10% of patients.

Question 2

What are the types of anorexia nervosa?

Answer 2

Restricting type

Binge-eating/purging type

Question 3

How is anorexia nervosa caused?

Answer 3

No underlying physical problems with food intake or absorption.
Abnormalities almost entirely attributable tot he following:
Starving or vomiting due to the use of emetics
Laxatives
Diuretics

Question 4

How does food intake affect the nutritional aspects of AN?

Answer 4

Decreased food intake.
Restrictive AN eat proportionally fewer calories from fat.
Proportionally more calories eaten as carbohydrate.
Usual or higher proportion of calories taken as protein.
Absolute decreases in micronutrient intake.

Question 5

How is absorption affected by AN?

Answer 5

Nutrient absorption expected to be normal.

Decreased ORAL glucose absorption.

Question 6

How are serum carotene levels affected by AN and what does it suggest?

Answer 6

Elevated serum carotene levels.

Suggestive of decreased hepatic metabolism.

Question 7

How is nutrition lost in AN?

Answer 7

D/t vomiting and the use of purgatives, laxatives, and diuretics

Question 8

What is commonly lost in AN?

Answer 8

Water
Na, Cl, K, Mg
H+ (w/vomiting)
HCO3 (w/diarrhea)

Question 9

What are the nutritional requirements of AN?

Answer 9

Lower metabolic rates than predicted.
Refeeding syndrome.
Protein restitution.

Question 10

How many calories above maintenance is needed to increase weight 1kg?

Answer 10

5000 - 7500kcal

Question 11

How many calories are required to restore body fat?

Answer 11

Requires up to 8000kcal/kg of fat

Question 12

For whom should a focused assessment be conducted?

Answer 12

On all patients and should include:
Hx
Physical Examination
Lab tests

Question 13

What should the history include in a focused assessment?

Answer 13

Weight 
Weight control
Beliefs about food
Frequency and duration of bingeing epidodes
Purging behaviors

Question 14

What should the physical exam include in a focused assessment?

Answer 14

Body measurements
Physical findings
When vomiting is a feature of illness (parotid enlargement, Russell’s sign)
Medical complications

Question 15

What lab tests are included in a focused assessment?

Answer 15

Hematologic changes are common
Electrolyte disturbances
ECG abnormalities

Question 16

What are the goals of therapy for AN?

Answer 16

Treatment of complications associated with condition.
Restoration of nutritional status to premorbid state.
Restore a normal body image so that normal nutritional status can be maintained.

Question 17

How are AN patients managed?

Answer 17

Hospitalization

Multidisciplinary approach required

Question 18

When are AN patients hospitalized?

Answer 18

Fluid and electrolyte abnormalities
Profound malnutrition
Rapid weight loss necessitating hospital admission
Other complications

Question 19

What are multidisciplinary approaches?

Answer 19

Psychiatrists
Internists
Nutritionists
Pharmacists
Nurses
Pediatricians

Question 20

What weights are obtained in the history?

Answer 20

Current
Premorbid
Highest and lowest
Women

Question 21

What weight controls are obtained in the history?

Answer 21

How patient lost weight
Helps to characterize class of AN

Question 22

What beliefs about food are included in the history?

Answer 22

Includes feelings about food allergies

Intolerances

Question 23

What is recorded about frequency and duration of bingeing episodes in the history?

Answer 23

Foods usually consumed

Question 24

What is recorded in the history for purging behaviors?

Answer 24

Use of emetics

Laxatives

Question 25

What body measurements are recorded in physical examination?

Answer 25

Height Weight BMI Anthropometric measurements

Question 26

What physical findings are receorded in physical examinations?

Answer 26

Muscle mass | SQ tissues stores

Question 27

What medical complications are recorded in a physical examination?

Answer 27

Volume depletion Weakness Dysrhythmias

Question 28

What hematologic changes are common in laboratory tests?

Answer 28

Anemia Neutropenia Thrombocytopenia

Question 29

What electrolyte imbalances are recorded in lab tests?

Answer 29

Hyponatremia Hypochloremia Hypokalemia Metabolic alkalosis

Question 30

What ECG abnormalities are recorded in lab tests?

Answer 30

``` Occur 60-70% of patients. Sinus bradycardia. Low amplitude QRS complexes. Nonspecific changes to ST and T waves U waves (hypokalemia) QT interval prolongation ```

Question 31

What are the goals of therapy?

Answer 31

Treatment of complications associated with condition. Restoration of nutritional status to premorbid state. Restore a normal body image so that normal nutritional status can be maintained.

Question 32

How is weight restoration achieved?

Answer 32

Consumption of a normal diet. Avoidance of "artificial" means of nutrition support. Slower rates of weight gain generally accepted.

Question 33

What are artificial means of nutrition support?

Answer 33

Liquid supplements | Tube feeding

Question 34

What topics are discussed for dietary counseling?

Answer 34

``` Types and quantities of foods eaten. Permitted to avoid only a limited number of foods. Important goal is to widen food choices. No hard guidelines on caloric intake. Frequent follow-up. ```

Question 35

What is the recommended caloric intake for outpatients with AN?

Answer 35

1000-1500kcal/day. Increase weekly by 250-500kcal/day. Goal weekly weight gain of 1kg recommended.

Question 36

What are the 3 phases of inpatient treatment?

Answer 36

Stabilization. Fluid and electrolyte repletion. Administration of micronutrients.

Question 37

What is monitored for inpatient treatment?

Answer 37

``` CBC - weekly BMP - daily for 3 days then every 3 days ECG rPTT or INR Ca, Mg, PO4 ```

Question 38

Refeeding syndrome

Answer 38

``` Occassionally delayed for 24 hours. Monitoring extremely important. Begin by providing 20-25kcal/kg body weight. 1000-1500kcal/d to start. Modest calorie increases in first week. ```

Question 39

When is it okay to administered parenterally?

Answer 39

When the gut is not intact. Severe gastric retention. Bowel obstruction from adhesions. Crohn's disease.

Question 40

When is tube feeding essential?

Answer 40

Very malnourished patients. When restoring body mass in patients incapable on their own. Gastric retention/rupture. Consider wastage by patient.

Question 41

What is a common tendency with parenteral nutrition?

Answer 41

Push calories more than with enteral. | Cardiac and pulmonary decompensation.

Question 42

What education should be given for AN?

Answer 42

Should be provided to both patient and caregiver. Nutrition counseling is a key component of therapy. Many educational aspects of therapy tend to be more behavioral. Encourage patients to become knowledgeable about nutrition and effects of starvation.