10/14/2013 Nutritional Management in Anorexia Nervosa Nutritional Management in Anorexia Nervosa  Nutrition screening and assessment  BMI, SGA (subjective global assessment)  Nutrition therapy  Who should be admitted?  How to prescribe diet & micronutrients?  What is the aim of treatment? Rattanachaiwong S. Subjective Global Assessment Body mass index A Classification Normal Overweight Obesity WHO criteria Asia-Pacific criteria <18.5 <18.5 18.5-24.9 18.5-22.9 25-29.9 23-24.9 ≥30 ≥25 • Obesity grade 1 30-34.9 25-29.9 • Obesity grade 2 35-39.9 ≥30 • Morbid obesity ≥40 - C การรับประทานอาหาร • ทานได้ปกติ • ทานได้ลดลง แต่มากกว่า ¾ ของปกติ • เปลี่ยนมาทานโจ๊ก หรือข้าวต้ม • เปลี่ยนมาทานแต่น้าๆ • ทานได้ลดลง แต่มากกว่า ½ • ทานได้ลดลง <1/2 ของปกติ ของปกติ น้าหนัก • เท่าเดิมหรือเพิ่มขึน • ลดลงแต่เพิ่มขึนแล้ว • ลดลง <5% ใน 1 เดือน • ลดลง < 10%ใน 6 เดือน อาการของทางเดิน อาหาร (ท้องเสีย, อาเจียน) • ไม่มีอาการ • มีอาการ < 2สัปดาห์แต่เป็น • มีอาการน้อยกว่า 2 ทุกวัน สัปดาห์และไม่ได้เป็นตลอด การท้างาน • ท้างานได้ปกติ • ท้างานได้ลดลง แต่ยัง ช่วยเหลือตัวเองได้ • ต้องมีคนช่วย ตรวจร่างกาย • ปกติดี • BMI > 18.5 kg/m2 • Edema • BMI < 18.5 kg/m2 • Ascites • BMI < 17.5 kg/m2  BMI = bogy weight(kg)/ height(m)2 Underweight B • ลดลง >5% ใน 1 เดือน • ลดลง > 10%ใน 6 เดือน • มีอาการมากกว่า 2 สัปดาห์ Subjective Global Assessment SGA class การแปลผล A ไม่มี หรือมีความเสี่ยงน้อยที่จะเกิดภาวะทุพโภชนาการ B มีความเสี่ยงสูงที่จะเกิดภาวะทุพโภชนาการ ต้องติดตามอย่างใกล้ชิด C มีภาวะทุพโภชนาการอย่างรุนแรง Nutritional Therapy in Anorexia Nervosa 1 10/14/2013 NICE guidelines for treatment of eating disorders 2004 “Most people with anorexia nervosa should be treated on an outpatient basis.” (C) “Inpatient treatment should be considered for people with anorexia nervosa whose disorder is associated with high or moderate physical risk.” (C) Markers of decompensation Treasure J, et al. Lancet. 2010 Feb 13;375(9714):583-93. Markers of decompensation Indications for admission American Psychiatric Association, 2000 - BMI < 16 kg/m2 weight loss more than 20% Modern Nutrition in Health and Disease 10th edition (2006) - dangerously low BMI metabolic complications suicidality/ self injurious behavior pregnancy DM type 1 National Institute for Clinical Excellence (NICE) 2004 - patient not improve with appropiate outpatient outpatient treatment moderate to high physical risk risk of suicide or self-harm - Markers of decompensation Treasure J, et al. Lancet. 2010 Feb 13;375(9714):583-93. Nutritional management in AN  3 regular meals a day aim total calorie 30-35 kcal/ kg actual body weight/day aim total protein 1.2-1.5 g/kg ideal body weight/day  expanding food repertoire  avoiding diet foods : fat-free, sugar-free products  limit weighing to once a week  aware of refeeding syndrome Treasure J, et al. Lancet. 2010 Feb 13;375(9714):583-93. 2 10/14/2013 Refeeding syndrome Thiamin as coenzyme Refeeding syndrome  hypokalemia  hypophosphatemia  hypomagnesemia  Thiamin deficiency Clinical presentations  peripheral edema, cardiac arrhythmia, neuromuscular weakness, nystagmus, gaze palsies, gait ataxia, internuclear ophthalmoplegia, psychosis (Wernicke-Korsakoff syndrome), heart failure, pulmonary congestion, lactic acidosis Thiamin as coenzyme Nutritional management in AN Prevention of refeeding syndrome  correct electrolytes imbalance before feeding (K, Mg, PO4)  start with low calorie first  slow titration +500 kcal every 2-3 days  Thiamin 100 mg IV OD x 3 days  recheck for electrolytes abnormalities during calorie titration  restrict fluid to sufficient to maintain renal function (2030 ml/kg/day) Diet prescription : first phase calorie specific example Treasure J, et al. Lancet 2010 5-10 kcal/kg/day low salt high phosphate milk-based product Modern Nutrition in Health and Disease 10th edition (2006) 1000-1200 kcal/day low salt Male RDA Female RDA MTV tablet Centrum Bco tablet B1-6-12 Vitamin B1 (mg) 1.2 1.1 5 2.25 5 100 Vitamin B2 (mg) 1.3 1.1 2 3.2 2 - vitamin/multi-mineral supplement in oral form is recommended for people with anorexia nervosa during both inpatient and outpatient weight restoration.” (C) Vitamin B3 (mg) 16 14 10 40 20 - Vitamin B5 (mg) 5 5 3 10 - -  Vitamin 200% RDI  +additional thiamin 100 mg/day for refeeding syndrome Vitamin B6 (mg) 1.7 1.5 1 3 2 5 Folic (mg) 0.4 0.4 0.1 0.4 - - Vitamin B12 (mcg) 2.4 2.4 1 9 - 65 NICE guidelines for treatment of eating disorders 2004 “In some cases treatment with a multi-  Mineral and trace element 100% RDI 3 10/14/2013 Refeeding induce an increased in REE in malnourished AN Aim for weight gain Treasure J, et al. Lancet 2010 National Institute for Clinical Excellence (NICE) 2004 Outpatient Inpatient 250-450 g /wk 1 kg /wk 0.5 kg /wk 0.5-1 kg /wk Modern Nutrition in Health and Disease 10th edition P<0.001 P<0.001 Resistant to weight gain!! Mean REE:FFM control group 131±15 ~ 1-2 kg /wk “Why did my patients not gain weight?” Van Wymelbeke V, et al. Am J Clin Nutr. 2004 Dec;80(6):1469-77. NICE guidelines for treatment of eating disorders 2004 “It is often unfair to accuse most of these AN patients of discarding their food when they do not gain body weight.” Any roles of parenteral nutrition? “Total parenteral nutrition should not be used for people with anorexia nervosa, unless there is significant gastrointestinal dysfunction.” (C) Van Wymelbeke V For our case  Actual body weight (ABW)  Height  Ideal body weight (IBW) = height-110 or ideal body weight at BMI 20 kg/m2 38 kg 156 cm = 46 kg = 20x1.56x1.56 = 48 kg  Aim TC 30-35 kcal/ABW/day = 1140-1330 kcal/day  Aim TP 1.2-1.5 g/IBW/day =55.2-69 g/day  Day 1 400-500 kcal/day + thiamin 100 mg IV ODx3days MTV 1x2, Bco 1x2 titrate 500 kcal q 2-3 days, F/U electrolytes Conclusions  Re-establish normal eating behavior  AN- aware of refeeding syndrome, volume overload  Micronutrients supplement in malnourished patients 4 10/14/2013 Medical complications of eating disorders Thank you  Hypercholesterolemia in anorexia nervosa Blendis LM, et al. Postgrad Med J. 1968 Apr;44(510):327-30. Proposed mechanism of hypercholesterolemia in AN       Cholesterol-riched food during binge behavior (AN-B) Low FT4/ or FT3 (lead to decrease hepatic LDL receptor) Mobilization of body fat during phase of weight loss Increase flux of peripheral cholesterol to liver Decreased hepatic LDL receptor Reduced bile acid formation (AN-R) Weinbrenner T, et al. Br J Nutr. 2004 Jun;91(6):959-69. Nestel PJ. J Clin Endocrinol Metab. 1974 Feb;38(2):325-8. Ohwada R, et al. Int J Eat Disord. 2006 Nov;39(7):598-601. Thank you The reciprocal pattern of cholesterol level in AN Serum cholesterol BW Blendis LM, et al. Postgrad Med J. 1968 Apr;44(510):327-30. Medical Complications of Eating disorders 5 10/14/2013 Medical complications of eating disorders Medical complications of eating disorders Skin  Russell’s sign         Xerosis Lanugo-like body hair Telogen effluvium Acne Acrocyanosis Carotenoderma Pruritis Purpura scar/callus formation over the dorsal surface of the hand, as the hand is used to stimulate the gag reflex to induce vomiting Mitchell JE, et al. Curr Opin Psychiatry. 2006 Jul;19(4):438-43. Medical complications of eating disorders Medical complications of eating disorders Endocrine : DM type 1 Gastrointestinal  somes report higher prevalence of AN among DM type 1  EDs increase risk of microvascular complications  worsen QoL in DM type 1         gastric dilatation gastric mucosal necrosis delayed gastric emptying gastric motor dysfunction impaired sense of hunger and satiety delayed small bowel transit time constipation Case report : pancreatitis, necrotizing colitis Mitchell JE, et al. Curr Opin Psychiatry. 2006 Jul;19(4):438-43. Mitchell JE, et al. Curr Opin Psychiatry. 2006 Jul;19(4):438-43. Medical complications of eating disorders Medical complications of eating disorders Cardiovascular and pulmonary Skeletal system          arrhythmia ; the most common cause of death prolonged QT bradycardia pneumomediastinum  spontaneous chest pain, may mimic acute MI osteopenia osteoporosis Low body weight predicts low bone mineral density Only weight restoration alone may not effective ? Bisphosphonate + calcium + vitamin D  acrocyanosis Mitchell JE, et al. Curr Opin Psychiatry. 2006 Jul;19(4):438-43. Mitchell JE, et al. Curr Opin Psychiatry. 2006 Jul;19(4):438-43. 6 10/14/2013 Medical complications of eating disorders Laboratory changes in AN Increase Hematology  hemoconcentration due to hypovolemia Decrease HCO3 (metabolic alkalosis) Cholesterol (TC, LDL, HDL) Aminotransferase enzymes Cortisol Hyperamylasemia Hypercarotenemia CETP activity Ketone bodies Apo-A1, B, C2, C3, E K (hypokalemia) Na (hyponatremia) BUN, Cr FT4, FT3 Gonadotropin hormone Mitchell JE, et al. Curr Opin Psychiatry. 2006 Jul;19(4):438-43. Elevation of Liver function test in Anorexia nervosa      rare complication of AN more likely to occur in BMI < 12 kg/m2 elevation of aminotransferase enzymes (AST, ALT) can vary from mild to severe liver decompensation, coagulopathy, hyperbilirubinemia and fulminant liver failure have been reported  peak level may occur after initiation of nutritional therapy Harris RH, et al. Int J Eat Disord. 2013; 46(4):369-74. Elevation of Liver function test in Anorexia nervosa 50% decrease within 2 and 5 days Rautou PE, et al. Gastroenterology. 2008;135(3):840-8 Elevation of Liver function test in Anorexia nervosa maximal elevation usually occur at the lowest body weight point 4500 4000 3500 3000 2500 AST 2000 ALT 1500 calorie tintake 1000 500 0 Day 0 Rautou PE, et al. Gastroenterology. 2008;135(3):840-8 Day 22 Day 28 Day 35 Day 40 Day 48 Adapted from Harris RH, et al. Int J Eat Disord. 2013;46(4):369-74. 7 10/14/2013 Elevation of Liver function test in Anorexia nervosa Elevation of Liver function test in Anorexia nervosa Proposed pathogenesis  ischemia  low glutathione level with resultant oxidant stress  starvation-induced hepatocyte autophagy  hepatic fat and glucose deposit (after refeeding) Histological findings and immunostaining  swelling and clarified hepatocyte  glycogen depletion (PAS staining)  centrilobular liver cell atrophy associated with mild sinusoidal fibrosis  ceroid pigment, predominant in centrilobular zone  autophagosomes in 4/12 cases  no significant hepatocellular necrosis, congestion  no markers of apoptosis found Harris RH. Int J Eat Disord. 2013;46(4):369-74. Rautou PE, et al. Gastroenterology. 2008;135(3):840-8 Autophagy Diffuse hepatocytic swelling Centriobular fibrosis and atrophy Low organelle-density hepatocyte Autophagosome sequestring cytoplasmic components Rautou PE, et al. Gastroenterology. 2008;135(3):840-8 Starvation-induced hepatocyte autophagy Autophagosome  double-membrane vesicle  sequestering other cytoplasmic components e.g. mitochondria, endoplasmic reticulum  fusion with pre-existing lysosomes  result in low density of organelles in hepatocyte  may lead to autophagic cell death Rautou PE, et al. Gastroenterology. 2008;135(3):840-8 Rautou PE, J Hepatol. 2010;53(6):1123-34. Starvation-induced hepatocyte autophagy Autophagy  well-known survival strategy under stress condition  supply macromolecules for biosynthesis during nutrientdeprivation  help to delay cell apoptosis  also can kill a cell “autophagic death” Rautou PE, et al. Gastroenterology. 2008;135(3):840-8 8 10/14/2013 Starvation-induced hepatocyte autophagy Approach to abnormal LFT in AN Abnormal LFT exclude other causes Alcohol, drugs and toxin Viral hepatitis : HBsAg, Anti-HBs, Anti-HBc, Anti-HCV, Anti-HAV Autoimmune hepatitis : ANA, anti-smooth muscle Ab, anti-LKM Wilson disease : serum ceruloplasmin Ultrasound / CT upper abdomen small liver, no fatty liver • continue feeding • should improve in 2-5 days Rautou PE, J Hepatol. 2010;53(6):1123-34. Medical complications of eating disorders Rautou PE, et al. Gastroenterology. 2008;135(3):840-8 Medical complications of eating disorders Rautou PE, et al. Gastroenterology. 2008;135(3):840-8 large liver, fatty liver • probably due to overfeed • consider reduction in calorie feed Adapted from Harris RH, et al. Int J Eat Disord. 2013; 46(4):369-74. Medical complications of eating disorders Rautou PE, et al. Gastroenterology. 2008;135(3):840-8 Medical complications of eating disorders Rautou PE, et al. Gastroenterology. 2008;135(3):840-8 9 10/14/2013 Medical complications of eating disorders Rautou PE, et al. Gastroenterology. 2008;135(3):840-8 Medical complications of eating disorders Rautou PE, et al. Gastroenterology. 2008;135(3):840-8 Medical complications of eating disorders Rautou PE, et al. Gastroenterology. 2008;135(3):840-8 10