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Anorexia Nervosa: A Case StudyColleen ShankSodexo Dietetic InternshipIntroductionIn February, 2014 I spent a few days at Manor Care in Lansdale, PA where I came across C.H. This patient took my interest right away; she came to Manor Care from a local hospital with several diagnoses including Failure to Thrive (FTT) secondary to malnutrition, Pancytopenia, Hypothermia, Bradycardia, and Hypotension. What intrigued me most about C.H. was her history of Anorexia Nervosa (AN) and how the disease is affecting her now in her mid-fifties. Since I found this case to be fascinating I knew that I wanted to learn more about AN as well as the role of medical nutrition therapy (MNT) and the RD in the treatment of AN. Before starting the research process, I needed to know what I was looking for and what outcomes I desired. I knew that I wanted to research AN to find out more about this topic and how it affects adults. Although the secondary diagnoses are also important to research, there would not be enough room in the presentation to discuss all of them in great detail. I believe that it is significant to look at the whole picture for this patient since her case is complex; there are many elements that come into play in this case including medical, social, psychological, and nutritional factors. By the conclusion of my research I wanted to learn more about AN as well as the treatment process for patients suffering from AN.AbstractThe purpose of this case study is to discuss AN including current and relative research on the condition. Also, this case study will delve into the MNT process for treatment and recommendations. The patient, C.H will be discussed in detail, examining her history, hospital course, and the nutrition care she received. First, a detailed discussion of AN will give basic information on the condition as well as a look into the current research and practice regarding AN. Next, MNT will be reviewed and will include up to date standards and practice recommendations for treatment of AN. Lastly this paper will look at C.H. and present her case. By conclusion of this case study the reader will have knowledge of the condition of AN, the current MNT guidelines for AN, and how those relate to the case of C.H. Discussion of Medical ConditionAnorexia Nervosa is a serious eating disorder that plays a major role in society today. In fact, Hoek and Van Hoeken 1 report, “there has been a rise in incidence of anorexia in young women 15-19 in each decade since 1930.” The fact that AN has been on the rise over the past several decades shows not only the prevalence of AN but that there is much information and research to explore regarding this topic.The Renfrew Center Foundation for Eating Disorders states, “up to 24 million people of all ages and genders suffer from an eating disorder (anorexia, bulimia and binge eating disorder) in the U.S.”2 This is a very large number of Americans that suffer from eating disorders and shows eating disorders are not uncommon. Even more unsettling is the fact that many of those who suffer from an eating disorder do not survive; The Renfrew Center also points out, “20% of people suffering from anorexia will prematurely die from complications related to their eating disorder, including suicide and heart problems.”2 Not only are there millions of people with eating disorders, but many of them will lose their life due to the severity of the disorder. Both males and females can suffer from anorexia, but “approximately 90-95% of anorexia nervosa sufferers are girls and women.”1 This illustrates that there is prevalence among women and girls suffering from AN. What’s more, teenage girls are more likely to suffer1; this displays the need for proper treatment and recovery since many of those suffering are young.There are 2 types of AN that are recognized today; the first type of AN involves the restriction of energy intake, called restricting type. This type can be damaging to one’s body because it does not allow the body to get the energy it needs, thus resulting in starvation. 2 Binge-eating/purging type is the second kind of AN; what this means is that after eating food (any amount) the person suffering from this type of AN either vomits or exercises intensely to rid themselves of the food they ate 2. The fear for persons suffering from both types of AN is weight gain; they feel the need to restrict their intake or get rid of what they consumed in order to control their weight rather than gain weight. 2Anorexia Nervosa is defined by an individual having a “distorted body image and excessive dieting that leads to severe weight loss with a pathological fear of becoming fat.” 3 This definition shows that AN is a complex disorder with many levels of both physiological and psychological effects. The specific criteria used to diagnose someone with AN can be found in the Diagnostic and Statistical Manual of Mental Disorders (DSM). In May of 2013, the American Psychiatric Association (APA) revised the DSM making the 5th edition available. Although the changes may be subtle, they assist professionals with diagnosing eating disorders. The following are the measures for diagnosing AN as stated in the DSM-54:1. Restriction of energy intake relative to requirements leading to a significantly low body weight in the context of age, sex, developmental trajectory, and physical health.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 self-evaluation, or denial of the seriousness of the current low body weight. Psychologists and Physicians must use the DSM-5 to diagnose a patient with AN. However, there are screening tools that can be utilized by health professionals to help assess if someone may be at risk for AN or another eating disorder. EDI-35 and Eat-266 are 2 such tests used by individuals as well as healthcare professionals to determine if there is a risk of an eating disorder. Both of these tests as well as several others can be found online and submitted for scoring which can tell an individual if they possibly need more evaluation by a professional. Although EAT-26 and other screening tools cannot diagnose an eating disorder, they are great tools for both the public and health care professionals. Determining a risk for an eating disorder may lead a person to get the help they need to recover. The Eating Attitudes Test also known as EAT-266 is an example of an assessment tool to determine risk for an eating disorder. After identifying ones gender, height, and weight, there are a total of 32 questions split into 2 sections. The first sections asks the participant to select a response determining how often they feel, experience, like, or avoid certain things; they must select one of the following options, always, usually, often, sometimes, rarely, or never. The second section asks the participant to identify behaviors such as vomiting, binging, and exercising and to define how often he/she experienced them; never, once a month, 2-3 times a month, once a week, 2-6 times a week, or once a day or more.6 Whether someone is suffering from food restriction, binging/purging, or both types of AN, they start to show physical signs. Among the visible signs are weight loss, tiredness, thinning hair, hair loss, dry skin, swelling of the arms/legs, among others.7 These symptoms do not just appear overnight; many of the signs and symptoms are caused by the internal damage occurring due to AN. The physical signs and symptoms are easier to see but there are also psychological symptoms of AN that are not as easily noticeable. The emotional signs may include, not wanting to eat, fear of weight gain, extreme exercise, depression, among others.7 Even though some of the signs can be seen and others are not as visible, the results of not being treated for AN can be damaging to a person and even life-threatening. 7Physiological changes are also taking place internally that cannot be seen. At this point, the bodies systems are being affected in different ways; the cardiovascular, neuroendocrine, renal, and gastrointestinal systems are negatively affected by AN. Some of the results of AN on these systems includes, slower heart rate, anemia, the stomach gets smaller, constipation, dehydration, amenorrhea in women, osteoporosis, hypothermia, and hypotension.7, 8 These effects further demonstrate the severity and complexity of AN. As mentioned previously, there are many complications of AN and in order to diagnose them there are tests that can be performed. A complete blood count (CBC) can help to determine if someone is suffering from anemia; testing electrolytes may also be necessary to see if there are any abnormalities which can affect the overall health of the patient; testing for total protein can indicate malnutrition as well as possible kidney or liver problems; testing the heart, liver, kidney, bones, and thyroid would assist in finding other possible damage to the body of someone suffering from AN.9The Nutrition Care Manual (NCM) defines several labs that are typically abnormal in AN. Although starvation is usually the cause of the abnormalities, other causes include vomiting, dehydration, and refeeding syndrome. According to the NCM the following labs and abnormalities are seen in AN, 10 Elevated cholesterolAbnormal lipoprotein profile Low zinc Low vitamin B-12 AlkalosisLow chloride and potassium Elevated bicarbonateHypomagnesmiaHypophosphatemiaBeta carotene elevated LeukopeniaLymphocytosisLow resting metabolic rate BradycardiaHypotension Mitral valve prolapse Serum albuminThese are all important to look at in AN because awareness of these irregularities helps the treatment team determine what abnormalities there are and what to look for in terms of improvement throughout recovery.The team of professionals working with AN patients would also want to look at other functions to make sure there are no other inconsistencies. Amenorrhea, for example, can occur in women causing low estrogen among other variances in hormones.10 Thyroid function may also be impaired and can be seen in patient’s also experiencing hypothermia or bradycardia among other symptoms.10 Lastly, blood glucose can be off as well showing low levels or the levels could remain within normal limits.10 These are significant things to look at since the body can go through so many changes due to the stress of AN.Due to the severity and complexity of this disease, the treatment and recovery process involves a team of professionals including, physicians, psychiatrists, and RDs who all play a part in the treatment of AN. Everyone who suffers from AN does not receive the same exact treatment because each individual has different issues and needs.11 For this reason each patient has an individualized treatment and recovery plan.Included in the treatment of AN and other eating disorders is a psychological, medical, and nutritional intervention. Treatment may include inpatient, outpatient, or a combination of both. Specialists who are trained to work with eating disorder patients all play an individual role in treatment but also work together to identify and treat the individual’s issues and complications.11The psychological treatment is provided by eating disorder specialists. Their role is to assist the patient and their family members depending on their individual situation. Psychological therapy can be one-on-one, group therapy, or patient and family therapy. According the APA, it is essential that the psychologist and patient “work together to explore the psychological issues underlying the eating disorder.”12 This is imperative to the treatment plan because without uncovering the fundamental issues, the patient would not be able to completely recover from their eating disorder. Family therapy can be especially helpful for adolescent girls. One such therapy is referred to as the Maudsley Approach.13 This approach aims to allow parents to, “help restore their child’s weight to normal levels expected given their adolescent’s age and height; hand the control over eating back to the adolescent, and; encourage normal adolescent development through an in-depth discussion of these crucial developmental issues as they pertain to their child.”13 Through 2 studies this type of therapy has shown, “approximately two thirds of adolescent AN patients are recovered at the end of FBT while 75 - 90% are fully weight recovered at five-year follow-up.”13 Although more research is needed on this specific approach, the APA discussed this treatment in an article in 2002 entitled “Promising Treatments for Anorexia and Bulimia,” thus showing it is being looked at as a treatment option.14 The Maudsley Model for treatment of adults with AN (MANTRA) has also been evaluated in research. A study done by Schmidt et al.15 set out to determine whether MANTRA is a useful treatment for adults. The researchers compared MANTRA with specialist supportive clinical management (SSCM) and found that there was no significant difference between treatments and the outcomes of the patients in regards to AN (patients from both groups showed improvement), however, “MANTRA patients were significantly more likely to require additional in-patient or day-care treatment than those receiving SSCM (7/34 v. 0/37; P = 0.004).”15A study published by Carter et al.16 assessed cognitive behavior therapy (CBT) and interpersonal psychotherapy (IPT) to ascertain their effectiveness as psychotherapy treatment for adult anorexia. They also used the SSCM (Specialist Supportive Clinical Management) as a control in the study. By the conclusion of their study, they were unable to find any significant difference between the 3 therapies stating, “Although SSCM was associated with a more rapid response than IPT, by follow-up all three treatments were indistinguishable.”16 As can be seen in this study and the study by Schmidt et al., there are a variety of therapies for patients but more research is needed to determine long-term effectiveness of these treatments. Pharmacotherapy is yet another area of treatment in which more studies are needed. The 3rd edition of the Guideline Watch: Practice Guideline for the Treatment of Patients with Eating Disorders has reviewed the literature and research on pharmacotherapy among other treatments for anorexia.17 Researchers have determined that there is “limited evidence for the use of medications to restore weight, prevent relapse, or treat chronic anorexia nervosa.”17 Although more research is needed, medications are still prescribed to AN patients for various reasons.Medication used in AN treatment is often times given to treat secondary or underlying problems such as anxiety and depression. Antidepressants as well as antipsychotics are sometimes used during treatment of AN. Examples of drugs include Olanzapine, Fluoxetine, Prozac, and Risperidone.18 These medications are not used to treat AN specifically but studies have been done regarding some of these drugs and weight gain in AN patients. In a study by Attia et al., 19 olanzapine was found to improve BMI in outpatient treatment of AN ([F(1, 20)=6.64, p=0.018]). However, the number of participants who completed the entire trial was small (17 out of 23 participants). Risperidone, on the other hand, did not have an effect on weight improvement in a study completed by Hagman et al.20 As with the study on Risperidone, a study on Fluoxetine also did not conclude any benefit in regards to weight restoration for AN patients.21 All 3 studies state that more studies are needed to determine benefit of weight restoration for AN patients taking any of these drugs.Discussion of Medical Nutrition TherapyThe Academy of Nutrition and Dietetics states in its position paper, 22 “Nutrition intervention, including nutrition counseling by a registered dietitian, is an essential component of the team treatment of patients with anorexia nervosa, bulimia nervosa, and other eating disorders during assessment and treatment across the continuum of care.”As can be seen in their statement the AND supports the RDs role in eating disorder assessment and treatment. It is essential to note this because many of the signs, symptoms, and complications of AN are indications for the RD to be involved in the treatment process. The role of the RD is to assess the patient, determine their nutrition diagnosis, identify a nutrition intervention, write the nutrition prescription, and define the nutrition goals.22Assessing the patient is the first step of the RD. Among the criteria that the RD will assess is the past medical history, current medical problems, physical and psychological symptoms, GI symptoms, weight history, lab values, and dietary history among other criteria specified by the individual facility. The 2011 practice paper of the ADA (now AND) states that, “a full nutrition assessment reveals current dietary intake, present eating patterns, history related to foods, nutrient deficiencies, supplement use, risk of refeeding syndrome, beliefs about food, binge purge patterns, and physical activity patterns.”23 Gathering this information is essential to the assessment of the patient so that the RD can properly identify any nutrition diagnoses.The NEDA (National Eating Disorder Association) toolkit for parents points out that “the goals of nutritional rehabilitation for seriously underweight patients are to restore weight, normalize eating patterns, achieve normal perception of hunger and satiety, and correct biological and psychological sequelae of malnutrition.”24 From this it can be seen that nutrition assessment and intervention is very significant in the treatment of AN.In the inpatient setting, the RD has to be aware of the current research on the treatment for AN patients. As mentioned previously, it is significant in the early stages to restore the patient both medically and nutritionally. The AND practice paper reiterates this and also states that this can involve a controlled eating environment and sometimes nutrition support.23 Furthermore, they mention the possible GI side effects related to refeeding of an AN patient which is critical for the RD to know.23Refeeding syndrome can occur when a starved patient is being re-fed; the clinical implications can include low levels of phosphorous, magnesium, and potassium in addition to thiamine deficiency.23 Glucose intolerance and fluid buildup are also consequences of refeeding syndrome.23 The ANDs practice paper reports that the protocol for refeeding suggests that both replacing and monitoring electrolytes and fluids is essential.23 It is thus imperative that RDs are aware of not only the potential effects of refeeding but also the protocol for proper refeeding of an AN patient. Since the goal of the RD and treatment team is to help the patient consume more food and reach their goal weight, each patient will have a nutrition prescription tailored to their needs. However, there are guidelines which can assist an RD in calculating needs. According to the NCM 1,200 kcal per day is the recommended starting point for energy needs.25After the starting point, energy can be increased slowly by 100-200 kcals every few days.26 Equations such as Mifflin St.-Jeor can be utilized to estimate REE but it may not be completely accurate.25 The assessment of the patient will help the RD determine their needs during the beginning and throughout their treatment.Weight gain is one of the goals of treatment; inpatient programs may wish to see 2-3lbs per week gained whereas outpatient programs may like to see 0.5-1.0lbs per week gained.26 To make sure weight gain continues, a patient may require >3,000kcal per day.26 Depending on inpatient versus outpatient status and prescription’s set for the patient, the RD can either assist in setting the meal plan for the patient to follow or counsel the patient to work towards his/her nutritional goals.26 Determining carbohydrate, fat, and protein needs may need to be tweaked for each patient, but again there are guidelines RDs can follow. Carbohydrate needs range from 50-55% of kcals, protein needs rage from 15-20% of kcal needs, and fat needs range from 25-30% of kcals.26 Micronutrients do not have recommended amounts like the macronutrients; a multivitamin with minerals may be advised.26 After determining kcal needs, the RD can decide what percentage of the calories will come from these macronutrients to best meet the patients’ needs. Enteral or parenteral nutrition support may be necessary depending on the patient’s status. The need for nutrition support will depend on specific factors including whether or not the patient is able or willing to eat by mouth.27 Parenteral nutrition should only be used if there is a medical need. Enteral nutrition could be necessary in addition to the patient eating by mouth in order to assist in weight gain27. As mentioned above, feeding too much too soon to a starved patient may cause refeeding syndrome. For this reason, it is vital that tube feedings be calculated correctly and advanced slowly to help reduce the risk of refeeding.27A study published in 2002 by Robb et al.,28 looked at overnight nutrition support in hospitalized anorexic patients. The anorexic adolescents who participated in the study were split into two groups; one group was re-fed orally while the other was re-fed with nutrition support overnight. The authors were looking specifically at changes in weight and BMI as well as how long the patients remained in the hospital. Even though further study is warranted, the researchers were able to see that overnight nasogastric refeeding (alone or supplemental) showed greater weight gain and weight restoration than with oral feeding alone.28 RD’s can learn from this study to help educate the team working with eating disorder patients and in their own practice. Presentation of the PatientC.H, a 56 year old female, presented to Lansdale Hospital on January 15th, 2014 complaining of weakness. Per patient records, her weight from the hospital was 74 pounds but it was not specific whether this was the admit weight or discharge weight. After being admitted, the hospital records show the following diagnoses, FTT secondary to malnutrition, Pancytopenia, Hypothermia related to malnutrition, Bradycardia related to hypothermia, and Hypotension related to dehydration. Anorexia, anemia, and wisdom teeth extraction were the only pertinent past medical history for this patient. The patient also stated that she was previously on an iron supplement but she discontinued taking it on her own due to negative side effects of which she did not state. Discussion of Medical Hospital Course/Manor Care CourseDuring the course of her hospital stay, it was noted that the patient was receiving tube feedings of Vital 1.5. There was no information regarding specifics of the tube feed but per the patient she had an NG tube. Also found in her hospital records was a history of a calorie count during her stay. The results of the 3 day calorie count showed that the patient ate between 2015 and 2705 kcals per day and 88-116g of protein daily. There were not many RD notes from the hospital but one note did reveal the patient had reported that her weakness did not just begin before her admission; it had actually started several months ago. She also reported weight loss beginning around the same time but was not specific with dates or amounts. C.H. was discharged from Lansdale Hospital on February 14th, 2014 and transferred to Manor Care in Lansdale. Upon admission to Manor Care her diagnoses were as follows, FTT, Gastroesophageal Reflux Disease (GERD), Refeeding Syndrome, Pancytopenia, and history of intussusception. She was noted to be "in an anorexic and malnourished state." Her admission anthropometrics were 76.6 pounds, 62.0 inches, and BMI 14.0. Her most recent labs were from February 21st, 2014 including, Random glucose: 78mg/dLBUN: 12mg/dLCreatinine: 0.40mg/dLK: 4.2mmol/LNA: 136mmol/LAST: 21 U/LALT: 30 U/LAlk phos: 66 U/LTotal bilirubin: 0.3mg/dLCa: 8.9mg/dLAlbumin: 3.6 g/dLTotal protein: 6.3g/dL GFR: >60mL/min/1.73 m2WBC: 6.6RBC: 3.96 LHGB: 9.3g/dL LHCT: 31.3% LMCV: 79.1fL LMCH: 23.4pg LAlong with several abnormal labs, C.H. also had skin issues. According to her Manor Care chart, she had a stage 3 gluteal wound and left lateral hip wound. Her medications while at Manor Care included the following:Cholecalciferol 2000 unit po dailyHeparin 5000 units SQFolic acid 1mg po dailyMVI po dailyProtonix 40mg po dailyZinc sulfate 220mg po dailyAs needed: Miralax, Colace, Tylenol, MOM, Dulcolax,Ferrous liquid 220g po daily (added at a later date 3x/week) Per patient records at Manor Care, she was originally placed on a gluten intolerance diet. The RD had not yet seen the patient for an initial visit but did start the patient on enhanced foods and a house supplement to help assist with further weight gain and wound healing. Once she was assessed by the RD, it was determined that there was no need for a gluten intolerance diet; there was no diagnosis of Celiac Disease or gluten intolerance and the patient stated she did not need a gluten intolerance diet. The patient was thus changed to a regular diet. C.H. lives at home with her mother and sister. There is no history of smoking, drinking, or drug use. On February 18th 2014, Manor Care was notified that the patient was to be under temporary guardianship of the Area on Aging (AOA). What this meant to the patient and her family was that the mother and sister were not allowed to bring in food for the patient; they were still allowed to visit with the patient but her meals were to come from Manor Care only. Discussion of Nutrition CareC.H. was first seen by the Manor Care RD on February 19th, 2014. This visit was an initial admission visit during which the RD gathered information to determine any nutrition related problems. Her current weight at this time was 77.2 pounds and her BMI was 14.1. During her interview with C.H., the RD was able to find out that the patient prefers “plain foods” and also has an intolerance to guar gum. Through diet history reported by the nursing staff, it was determined that C.H. had been consuming 75-100% of her meals and eats her meals slowly (1-1.5 hours per meal). There was no noted diarrhea, constipation, steatorrhea, communication, dental/oral, or functional problems noted at this time by the RD. The RD was able to complete her initial assessment on February 19th, 2014. Using C.H’s ideal body weight of 110 pounds, the RD was able to determine estimated energy, protein, and fluid needs. Due to the patient being underweight and desiring a weight gain, her calorie needs were estimated using 35kcal/kg to provide 1750kcal/day. Due to her current conditions including a pressure ulcer her protein needs were estimated using 1.5g/kg to provide 75g/day. Finally, her fluid needs were determined using 30mL/kg to provide 1500mL/day. The RD decided to continue with the regular diet, discontinue the enhanced foods (since patient likes plain foods), and continue the supplement TID. Recommendations from the RD included weekly CMP, CBC, P, Mg, and LFTs. She also recommended starting an iron supplement due to history of anemia. The patient was weighed weekly until discharge with the following weights recorded:2/14/14 76.6 pounds2/18/14 77.2 pounds2/24/14 77.6 pounds3/4/14 82 poundsThe plan of care for the patient while at Manor Care included:Debility: continue physical and occupational therapyFTT: continue current diet, supplements, folic acid, MVI, zinc, labs as scheduledIntususception: follow up with GI at the hospital as scheduledWound: local care with santyl, daily dressing change/pressure relief, nutritional supportWhile at Manor Care, the patient was assessed by a Med Options professional for a mental health evaluation. It was determined that her main issue to be addressed was anorexia nervosa. From this assessment, it was learned that the patient had suffered with weight since her teenage years; unfortunately no specifics were obtained from this information except that she had suffered from AN. It was also determined that C.H. had difficulty with mood functioning, behavioral functioning, and lack of insight. During the 2 visits by Med Options the patient made statements including, "I am not an anorexic," and "I do eat- I like food but I have a difficult time keeping the weight on."Since my time at Manor Care was limited, I was not able to spend a lot of time with the patient in person. However, I was able to interview her on one occasion. During this interview we discussed her usual intake, usual body weight (UBW), and history of recent weight loss. Her usual intake consists of 3 meals per day (breakfast, lunch, and dinner) as well as snacks in between meals. For breakfast she would eat things such as cold cereal with whole milk, fruit, eggs, hot cereal, and orange juice. For lunch she would eat foods including grilled cheese, chicken, soup, whole milk, fruit juice. Dinner consisted of a meat, starch, and vegetable with whole milk to drink. Snacks included banana, raisins, and cookies. She also reported that she would usually snack at night. In terms of her weight history, I was able to obtain a UBW range from C.H. According to C.H her UBW varied from 110-115# but more recently since she has been sick she states her weight has been between 85-90#. She explained to me that once she started getting sick she could notice she was losing weight but she was not keeping track of her weight loss at the time. One other interesting thing to note was that she reported to me that when she was taking her iron pill this would help her to gain weight but she stopped taking it due to negative side effects she experienced. SummaryAnorexia Nervosa is not only a very serious eating disorder, it is also very complex; there is no one treatment fits all approach to AN. Although some of the signs and symptoms of AN are easy to spot, there are other symptoms taking place internally that are damaging to the body. The complications of AN involve physical, psychological, and nutritional issues that need to be addressed throughout treatment. RDs are part of the team of specialists that play a role in the treatment of AN; the team works together to help determine the best approach for each individual patient. Although her main diagnosis was not AN, it is clear from her history that she has suffered from AN in the past. At the time of her discharge from Manor Care, C.H weighed 82 pounds. Unfortunately there were no new labs to report after my time with C.H at Manor Care. She was discharged back home with her mother and sister but again, there was no new information regarding the AOA; it can only be assumed that her care was returned to her mother and sister. Medication BibliographyMedicationWhat it is used forDrug/nutrient interactionsCholecalciferol (Vitamin D3)Vitamin/ Ca regulatorNoneHeparin AnticoagulantNoneFolic Acid (Folate)B complex vitamin/ AntianemicNoneMVIMultivitamin with IronNoneProtonix (Pantoprazole)AntiGERDMay decrease absorption of Vitamin B12 and FeZinc sulfateMineral SupplementShould be taken at least 2 hours apart from Cu, Fe, Ca supplements, high fiber foods, protein with a lot of PFerrous liquidIron supplementBran, high phytate foods, fiber supplement, tea, coffee, caffeine, red grape juice, wine, soy, dairy, egg should be avoided 1 hour before or 2 hours after iron supplement*As needed: NameWhat it is used forDrug/Nutrient interactionsMiralax (polyethelyne glycol)LaxativeShould have high fiber diet with 1500-2000mL fluidColace (Docusate Sodium)Stool softenerShould have high fiber diet with 1500-2000mL fluid; water and electrolyte absorption may be inhibitedTylenol (Acetaminophen)AnalgesicCaffeine increases the effectMilk of Magnesia (Manesium hydroxide)Laxative/AntacidShould have high fiber diet with 1500-2000mL fluid; Fe and Fol supplements should not be taken at the same time (take 2 hours apart)Dulcolax (Bisacodyl)LaxativeShould have high fiber diet with 1500-2000mL fluid; Milk/milk products, Ca, Mg should not be taken together (take 1 hour apart)Pronsky Z, Crowe J. 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Guideline Watch: Practice Guideline for the Treatment of Patients with Eating Disorders. 3rd ed. APA. 2012. . Accessed April 10, 2014. \Mickley D. Medication for Anorexia Nervosa and Bulimia Nervosa. Eating Disorders Recovery Today. 2004; 2(4). . Accessed April 11, 2014.Attia E, Kaplan A, Walsh B, et al. Olanzapine versus placebo for out-patients with anorexia nervosa [Abstract]. Psychological Medicine. 2011; 41(10): 2177-2182. DOI: Accessed April 11, 2014. Hagman J, Gralla J, Sigel E, et al. A Double-Blind, Placebo-Controlled Study of Risperidone for the Treatment of Adolescents and Young Adults with Anorexia Nervosa: A Pilot Study. JAACAP. 2011; 50(9): 915-924. DOI:10.1016/j.jaac.2011.06.009.Walsh T, Kaplan A, Attia E, et al. Fluoxetine After Weight Restoration in Anorexia NervosaA Randomized Controlled Trial. JAMA. 2006;295(22):2605-2612. DOI:10.1001/jama.295.22.2605.Ozier A, Henry B. Position of the American Dietetic Association: Nutrition Intervention in the Treatment of Eating Disorders. JADA. 2011;111:1236-1241. Accessed April 11, 2014. Waterhous T, Jacob M. Practice Paper of the American Dietetic Association: Nutrition Intervention in the Treatment of Eating Disorder. ADA. 2011; 11(8): 1261. Accessed April 10, 2014. Parent Toolkit. NEDA. 47. . Accessed April 11, 2014.Anorexia Nervosa Nutrition Prescription. Academy of Nutrition and Dietetics Nutrition Care Manual. . Accessed April 10, 2014.Schebendach J. Nutrition in Eating Disorders. In: Mahan LK, Escott-Stump S. Krause’s Food & Nutrition Therapy. St. Louis, MO; Saunders Elsevier; 2008: 563-586.Anorexia Nervosa Nutrition Support. Academy of Nutrition and Dietetics Nutrition Care Manual. . Accessed April 11, 2014.Robb A, Silber T, Orrell- Valente J, Valadez-Meltzer A, et al. Supplemental Nocturnal Nasogastric Refeeding for Better Short-Term Outcome in Hospitalized Adolescent Girls With Anorexia Nervosa. Am J Psychiatry. 2002;159:1347-1353. DOI:10.1176/appi.ajp.159.8.1347. Accessed April 11, 2014. ................
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