Ch10 malnutrition/underweight and ED's

MALNUTRITION AND WEIGHT LOSS

being underweight has risk for

health

Hight rates of famine and food insecurity can be found in what countries/places?

Haiti, south Sudan, and occupied Palestinian territories

also be found in south and southeast Asia and other parts of Africa

being underweight is a increasing problem in what population?

 adults 65 and older (3.1-25%)

being underweight is defined by what BMI?

<18.5

mini-nutritional assessment (AMA), SGA/PG-SGA, and frail scale are assessedments for?

risk of malnutrition, sarcopenia, and frailty

which assessment is usually used for older adults? if that one is not feasible?

• Mini-nutritional assessment (MNA)- older adults

• SGA or PG-SGA when MNA not feasible

the frail scale

• 3+ positive answers = frail

• 1 or 2 = prefrail

what are the medical risk factors and possible causes for malnutrition/weight loss in older adults? (8)

• Poor dentition

•  Loss of taste and smell

• Emphysema

• Malabsorption

• Diabetes

• Stroke, Parkinson’s disease

• Drug interactions

• Poor mobility, arthritis

• Cancer

what are the main 3 categories of risk of older adults for malnutrition and weight loss

• hospitalization

• lifestyle/social factors

• psychological factors

how may hospitalization increase risk for malnutrition and weight loss (4)

• Need assistance with eating

• Unpleasant sights, sounds, and smells

• Missed meals due to medical tests

• Increased nutrient needs

how may lifestyle/social factors increase risk for malnutrition and weight loss (4)

• Lack of knowledge about foods and cooking

• Isolation/loneliness

• Financial concerns

• Lack of access to transportation

what psychological factors may increase risk for malnutrition and weight loss (4)

• Confusion

• Dementia

• Anxiety

• Grieving

EATING DISORDERS

what are eating disorders?

Psychiatric condition characterized by severe disturbances in eating behaviors that result in significant physiologic impairment

the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) recognizes which ED’s

• Anorexia nervosa (AN)

• Atypical anorexia nervosa (atypAN)

• Bulimia nervosa (BN)

• Binge eating disorder (BED)

• Avoidant/restrictive food intake disorder (ARFID)

Disordered eating includes what behaviors

unhealthy/unhelpful eating behaviors like frequent dieting, refusal to eat certain macronutrients, and skipping meals

how does disordered eating differ from ED’s?

disordered eating does not tend to negatively impact health while eating disorders do

what is Anorexia Nervosa (AN)

Restriction of energy intake relative to requirements, leading to significant low body weight in the context of age, sex, developmental trajectory, and physical health (less than minimally normal)

AN is characterized by what main characteristic?

an intense fear of weight gain or becoming fat

AN occurrence rates

• more common in females than males (10:1)

• More common in postindustrialized, high income nations

what is atypical AN?

 meets all criteria and has loss significant weight BUT is not underweight

what are the 2 types of AN?

restrictive and binge-purge type

what is AN-restrictive?

Extreme dietary restraint used to achieve low BW AND During last 3 months has not regularly engaged in binge eating or purging

excessive exercise is common

what is AN-Binge-purge type?

Binge eating followed by compensatory behaviors

• Self-induced vomiting

• Laxative, enema, or diuretic misuse

• Combination

has occurred at least 1x a week for the past 3 months

are restrictive AN and binge-purge type isolated?

there tends to be cross-over between the 2

with low weight loss, what are other things that should be considered?

Weight history, body frame, and physiological disturbances

what is commonly seen in AN individuals but is no longer part of criteria?

amenorrhea

how can Prepubescent males and females experience sexual maturation arrest

• Males: testosterone deficiency

• Females: delayed menarche (first menses not occur by age 14)

what are the risk factors for AN?

• Drug, alcohol abuse

• Psychiatric disorders

  • Anxiety disorders, panic disorders, obsessive compulsive disorder

• Influential social factors

  • Cultural settings where thinness is valued

  • Professions that value lean physique (models, athletes)

• Personality traits

  • Rigid, inflexible thinking, lack of spontaneity, perfectionism, low self-esteem, need for control

what is the prognosis for AN?

• Course and outcome variable

• Many adopt a new eating behavior, such as vegetarianism, prior to developing the disorder

• Can become more severe the longer it is present

AN clinical complications (signs, side effects, etc) -14

• Brittle hair and nails

• Lanugo

• Ketotic breath

• Cyanosis of the extremities

• Carotenoderma

• Hypothermia or cold intolerance

• Protein energy malnutrition

• Bradycardia

• Cardiac arrythmias

• Orthostatic hypotension

• Delayed gastric emptying

• Severe constipation

• Decreased small bowel motility

• Peripheral edema

what occurs to REE in AN individuals?

it decreases due to weight loss

once those with AN start to refeed, what occurs to REE?

increases —→ leading to hypermetabolism

AN effects on bones

Bone mineral density decreases

AN impacts of hormones

• low leptin

• low T3

• decreased testosterone and reproductive hormones

AN and mortality

• Mortality rate for AN is 5% per decade

• Higher for AN compared to other EDs

Predictors of AN relapse include

age, psychosocial functioning, preoccupation with and misperception of body weight and shape, and individual psychotherapy

what is bulimia nervosa (BN)

Characterized by recurrent episodes of binge eating followed by one or more compensatory behaviors to avoid weight gain

what is a binge

eating within any 2-hour period an amount definitively larger than what most individual would eat in a similar period under similar circumstance

what are the characteristics of a binge

• Accompanied by feelings of loss of control and severe body dissatisfaction

• Usually take place in secrecy

• Accompanied by feelings of guilt and shame

• Foods can be unique, but typically include energy dense snacks and desserts an individual would normally avoid

• Can have “triggers” such as interpersonal stressors, dietary restraint, boredom, feelings of body dissatisfaction

what are the “purging” behaviors involved with BN

Compensatory behaviors: self-induced vomiting, misuse of laxatives, diuretics, medications, fasting, excessive exercise

binge and purge cycle needs to occur how often to be BN

Occur on average at least once a week for 3 months

body weight and size commonly seen in those with BN

Generally maintain body weight at or above normal (differentiates from binge-purge AN subtype)

BN risk factors

• Psychiatric disorders

  • Anxiety, depression, personality disorder, social anxiety disorder

• Personality traits

  • Low self-esteem, multiple weight loss efforts, strong desire to lose weight leading to frustration

• Family, environmental

  • Parental obesity, childhood abuse (sexual or physical abuse)

• Physical traits

  • Early pubertal maturation, obesity

• Substance abuse

BN average onset age

20 years old

BN usually initiated when?

 during or after a dieting attempt or stressful event

when vomiting, what signs and symptoms can help identify the disorder

Eroded dental enamel, dental caries, gingivitis, enlarged parotid glands, and Russell’s sign

what are russell’s sign

 the scarring by the teeth on the lower dorsum of the hand used to stimulate the gag reflex

chronic vomiting leads to what complications

lead to dehydration, alkalosis, and hypokalemia

AND manifested as sore throat, esophagitis, subjunctive hemorrhage, and mild hematemesis (vomiting blood)

serioud complications of BN (vomiting) (3)

• Mallory-Weiss tears or tears in the mucosa of the stomach esophagus junction

• Esophageal rupture

• Acute gastric dilation

laxative misuse possible side effects (7)

• Dehydration

• Elevated aldosterone and vasopressin levels

• Rectal bleeding

• Abdominal cramping

• Intestinal atony

• Rectal prolapse

• Dependence on laxatives to stimulate bowel movements

AN and BN similarities and differences

which BN patients are at higher risk for relapse? lower?

who experience full remission for 1 year after treatment have better long term outcomes than those that relapse within the first year

what are the predictors of BN relapse?

• Level of psychosocial functioning

• Weight or body shape anxiety

• Lower scoring on the Global Assessment Functioning Scale

• Higher mania scoring on the Psychiatric Status Rating Scale

Bing eating disorder (BED) is what

Characterized by recurrent binge eating episode that are not followed by compensatory purging or nonpurging behaviors

BED is characterized by what key characteristics

• Characterized by lack of control over eating during episode.

• Marked distress regarding binge eating

• Occurs on average at least 1 day a week for 3 months

• Not associated with in appropriate compensatory behavior

• Includes severity rating

binge eating is associated with 3 or more of the following (what are they)

• Eating much more rapidly than normal

• Eating until uncomfortably full

• Eating large amounts of food when not feeling physically hungry

• Eating alone because of being embarrassed by how much one is eating

• Feeling disgusted with oneself, depressed, or very guilty after overeating

those with BED general body type/size

 have overweight or obesity

BED is commonly seen in what population group

those seeking bariatric surgery

BED onset age

average of 25 years old

BED and dieting relationship

Attempts at dieting tend to follow the development of the disorder

instead of before like in BN

Course of journey in BED is comparable to what ED in terms of severity and duration

BN

BED increases risk for

weight gain, obesity, T2DM, CVD

increases risk for medical morbidities and mortality

Studies reveal that individuals with BED experience what tings in comparison to healthy (mentally) individuals

greater functional impairment, lower QOL, increased healthcare utilization, higher lifetime prevalence of substance abuse, major depression, and personality disorders

BED and relapse

• Those who seek treatment tend to be older than those who seek treatment for other EDs

• Higher rate of relapse

• Common for lost weight to be regained within first year

what is avoidant/restrictive food intake disorder (ARFID)

“An eating or feeding disturbance (e.g., apparent lack of interest in eating or food; avoidance based on the sensory characteristics of food; concern about aversive consequences of eating) as manifested by persistent failure to meet appropriate nutritional and/or energy needs”

ARFID presents itself with 1 or more of what characteristics? (4)

• Significant weight loss (or failure to achieve expected weight gain or faltering growth in children)

• Significant nutritional deficiency

• Dependence on enteral feeding or oral nutritional supplements

• Marked interference with psychosocial functioning

what is orthorexia

Referred to as obsessive eating behaviors that are focused on eating only a narrowly defined group of foods deemed to be “healthy” and “pure”

orthorexia and DSM-V

Not a recognized diagnosis by the DSM 5

what are the general common features of ED’s (4)

• Disturbed body image

• Perceive self as obese

• Intense fear of weight gain and obesity

• Relentless drive to lose weigh

ED’s often begin with

dieting and weight loss progression

Persons predisposed to eating disorders are seen to have what behaviors

 diet more strictly and develop characteristic psychological, behavioral, and medical problems associated with eating disorders

risk factors for ED’s include what categories (4)

• Environmental factors

• Character traits

• Comorbidities of psychiatric and mental health disorders

• Biological factors including genetics

ED treatment requires what type of approach

Interdisciplinary team approach

• Medical

• Nutritional

• Psychiatric/behavioral

for underweight individuals with ED’s the initial treatment goal is to

 normalize eating patterns and weight

role of the medical team in ED’s

• Baseline general medical and psychiatric assessment should be performed at the time of diagnosis

• Medical complications should be treated as needed

Behavioral/psychotherapy treatment include what types (therapy styles)- 5

• Cognitive behavior therapy (CBT)

• MANTRA

• Maudsley Model of cognitive interpersonal therapy

• Specialist supportive clinical management

• Family-based treatments

Entry-level RDN should know what in terms of ED’s

where to access medical and nutritional guidelines as well as recognize signs and symptoms of all disordered eating diagnoses

what are the goals for inpatient individuals with AN (diet)

• Correcting starvation (PO diet, TF as needed)

• Correcting fluid and electrolyte imbalances

what are the goals for inpatient individuals with AN (medical signs)

Correcting bradycardia and/or hypotension

inpatient wanted weight gain per week for AN

Weight gain 2-3 lbs per week

for AN individuals in outpatient, what professionals/treatments are involved?

• Team oriented (Physician, psychologist, RD, family)

• Psychotherapy

what is the goal of outpatient AN treatment (2)

• Promote healthy eating habits

• Goal - normal menstrual cycle

weight gain for outpatient AN recovery

0.5-1 lb per week

for AN, when reintroducing food what occurs

Reintroduction of food causes increase in diet-induced thermogenesis —→ hypermetabolism for 3-6 months

when does REE normalize normally

 normalizes as food intake becomes adequate

caloric needs for weight gain in AN patients

• initial needs

• increases recommended

• needs for weight gain in severe cases

• average females and male caloric needs (totals)

• 30-40 kcal/kg initially or 1000-1600 kcal/day

• Increase 200-300 kcal daily (American Psychological Association)

• May require up to 70-100 kcal/kg for wt gain

• Females may need 3500+ kcal and males 4000+ kcal daily

what is refeeding syndrome?

Metabolic shift from starvation to refeeding causes intercellular uptake of glucose, potassium, phosphorus, and magnesium resulting in low serum levels

• Driven by carbohydrate inducing insulin action

who are at risk for refeeding syndrome (in general)

severely malnourished patients or when oral, enteral, or parenteral nutrition intake is introduced within first week of treatment

due to risk of refeeding syndrome, what should be supplemented?

 provide supplemental potassium, phosphorus, magnesium, and thiamine

refeeding syndrome is a risk if individuals have 1+ of the following: (4)

• BMI <16

• Unintentional weight loss of >15% of body weight in the last 3 to 6 months

• Very little or no nutritional intake for more than 10 days

• Low K+, Phos--, or Mg ++ levels prior to feeding

refeeding syndrome is a risk if individuals have 2+ of the following: (5)

• BMI <18.5

• Unintentional weight loss of >10% of body weight in the past 3 to 6 months

• Very little or no nutritional intake for more than 5 days

• History of chronic drug use (insulin, diuretics, antacids)

• Alcohol or drug abuse

for BN, what type of approach is take (professionals involved)

Team approach (MD, RD, Psychologist, Family)

for BN, what are the goals (8- physical, mental, behavioral)

• Healthy weight maintenance

• Cessation of binge-purge cycle

• Restoration of normal eating pattern

• Correct nutrient deficiencies

• Stabilize fluid / electrolyte balance

• Recognition of hunger and satiety cues

• Stress management

• Oral health

BN and weight loss during treatment (can it be a goal?)

• Weight loss should not be the initial goal of intervention and should not be explored until after treatment.

• Weight loss may be a reasonable long-term goal for some individuals

BN energy needs compared to AN

Generally, patients with BN will require lower calorie intake to restore or maintain weight than patients with AN

what is common regarding weight in BN

weight fluctuations

why may weight fluctuations occur in BN?

• purging

• Weight loss may result from dehydration, followed by weight gain from rebound fluid retention

• Individuals who abruptly stop abusing laxatives or diuretics may experience significant fluid retention for several weeks

• Edema, fluid retention, and swollen salivary glands that can result from purging behaviors may be mistaken as true weight gain

what is recommended in BN treatment based on meals

• Recommend a structured meal plan

  • Avoid long periods of fasting so that cravings decrease and satiety and nutritional adequacy is promoted

  • Restrict intake below energy needs to avoid triggering binge eating episodes