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Kathryn Cornwall
Sodexo Dietetic Internship, Philadelphia
March 5th, 2015

The Challenges of Medical Nutrition Therapy for Anorexia Nervosa

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Table of Contents
Abstract.3
Introduction...4
Discussion of the Disease..4
Eating Disorder Statistics
Types of Eating Disorders
Diagnosis: DSM-V and Medical Criteria
Symptoms and Complications
Labs
Medical & Psychological Treatment
Medical Nutrition Therapy for Anorexia20
The Role of the R.D.
Nutrition Assessment
Intervention with the Anorexia Patient
Caloric Needs
Macronutrient Needs & Micronutrient Needs
Goals and Monitoring
Supplementation v. Nutrition Support
Presentation of the Patient.28
Critical Comments.38
Summary39
Terminology..................................................40
Medication Bibliography...................................................41
Appendix42
References..46

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Abstract
Anorexia Nervosa is not just a diagnosis. Its not just a certain type of person. It
can affect both men and women, young and old. It is not just someone who does not eat. It is not
just someone who wants to be thin. Anorexia is a disorder that encompasses the individual it
affects, both inside and out, both mentally and physically. It is often more than just what it
appears on the outside. Anorexia can be a lifelong battle. It can be a daily struggle. The person it
affects needs motivation to battle their eating disorder and a support system behind them in order
to be most successful. A part of the recovery process should include a team of professionals. One
of the most important players in this team can be the dietitian. The role the dietitian plays turns
into more than just medical nutrition therapy; it turns into being an integral part of the patients
support team.
Anorexia is a type of eating disorder in which the person experiences excessive
thoughts of gaining weight or a have a fear of being fat, along with avoidance of food,
restriction of food, and typically a distorted self-image or body-image. All of these factors
combined can cause metabolic changes that can result in life-threatening consequences
medically. Oftentimes, other psychological disorders such as anxiety or depression can also play
a role in an eating disorder. Due to these various co-morbidities, there is not just one- way to
treat an eating disorder. However, there are valuable steps clinically a dietitian should be
following in order to promote the most helpful treatment and best possible outcome for their
patient.

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Introduction
It was initially a challenge making a decision about what direction to take this case study
in. However, after working as a counselor with eating disorder patients for the past five years I
found myself realizing that I have always been on the therapy side of a treatment team and not on
the clinical nutrition end. It made sense to me to take what initially drew me into the world of
nutrition and learn as much as I could about the physiological side of anorexia from the
dietitians standpoint. It takes so much effort, not only on the patients part in the treatment of
this disorder but especially as the dietitian, to overcome the thoughts and behaviors that create
such an unhealthy lifestyle. My goal is to learn as much as I can about the role of the dietitian in
the treatment of anorexia and just how he or she can help in keeping the patient medically stable
but also provide the appropriate nutrition counseling to help the patient succeed in their recovery.

Discussion of Disease
Statistics
The recent statistics on eating disorders in this country are staggering. In the United
States alone, 30 million people, including both men and women, will suffer from an eating
disorder at some point in their lifetime.1 This number is likely much higher since it is estimated
that many of these cases go unreported for a variety of reasons. Eating disorders are not just a
temporary concern; they can affect someone for their entire lifetime, and often intermittently.
They are not just a mental health disorder but can include a complicated medical case especially
in the long term. Eating disorders are complex and have severe health consequences if left
untreated.2 No matter what the eating disorder, binge eating disorder, anorexia nervosa, bulimia
nervosa, or EDNOS, the overall health outcomes can be very scary. Anorexia in particular has

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the highest mortality rate of the psychiatric diagnoses. 3 Oftentimes, anorexic patients cannot see
just how serious their condition is which can be a major contributing factor to just how bad their
physical situation can get medically. 5-20% of anorexia patients will die. 2 Knowing this statistic
alone shows just how imperative not only a mental health intervention is but also that a clinical
nutrition intervention is needed.
Types of Eating Disorders
The Diagnostic and Statistical Manual of Mental Disorders is used in the psychiatric
practice to diagnose the type of eating disorder a person has. Currently, the Fifth Edition has
specific guidelines for anorexia nervosa, bulimia nervosa, binge eating disorder, and other
specified feeding or eating disorders which are grouped into two categories: OSFED and UFED.
OSFED stands for other specified feeding or eating disorder and unspecified feeding or eating
disorder. Previously, EDNOS was the category for eating disorders not other-wise specified.
The DSM-V updated this into the OSFED, UFED category. For psychiatric purposes as well as
insurance purposes, they use this diagnostic manual to develop treatment plans and guidelines for
understanding the specific disorder.
Anorexia nervosa, in the guidelines of the DSM-5, is diagnosed based off the following
traits:

Calorie/Energy restriction

Significantly low body weight

Fear of weight gain

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Fear of being fat

Distorted body image

Underestimating the seriousness of their health condition or low weight 5

Bulimia nervosa, in the guidelines of the DSM-5, is diagnosed based off the following
traits which occur on average a least once a week over a three month time period:

Frequent periods of binge eating involving:

o Eating copious amounts of food within a specific period of time
o Feelings of lack of control during binge period or unable to control how
much they are eating

Frequent episodes to avert weight gain including behaviors such as:

o Purging or inducing vomiting
o Laxative, diuretic, or diet pill abuse
o Fasting periods
o Over-exercise; compulsive exercise

Self-worth is based off body image, evaluation of self and body shape

Binge and purge behavior does not exclusively happen during anorexia episodes 5

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Binge eating disorder, in the guidelines of the DSM-5, is diagnosed based off the
following traits:

Eating copious amounts of food within a specific period of time

Feelings of lack of control during binge period or unable to control how much
they are eating

Episodes of binging including three or more of the following:

o Eating quickly, rapidly
o Eating until being unpleasantly full
o Eating regardless of hunger
o Eating alone based off shame around eating such large amounts of food
o Feeling upset after eating or guilty, shameful

Stress around binge eating

Binge eating when other periods or behaviors of bulimia or anorexia are not
present 5

There are many other possible eating disorders that can be considered when feeding and
eating behaviors are being considered. Pica, rumination disorder, and avoidant/restrictive food
intake disorder are all more symptom-specific based eating disorders but tend to be less common
than the disorders listed above. OSFED diagnoses must be made when a person has eating

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behaviors that are clinically significant issues and have symptoms that cause problems with their
functioning but do not meet the full criteria of other eating disorder criteria. UFED is when
behaviors cause the same problems and impairments but do not meet any of the criteria of other
eating disorders. 5
Diagnosis of AN
Beyond the DSM-V criteria used to diagnose, there are other medical criteria and testing
that is performed to help affirm the diagnosis. There can be multiple tests, exams, questionnaires
used to try to identify the main symptoms and if there are any other medical complications
arising on top of the eating disorder. A physical exam, complete blood counts, bone scans, EKGs
and other tests can all be used to pinpoint the exact symptoms and problems. 6
It is appropriate for the patient to have a standard physical exam. Evaluating their height,
weight, BMI, growth chart plotting when applicable, vital signs, and their overall appearance is
an imperative part of diagnosis. Typically BMIs of <17.5 are considered a clinical indicator.7 If a
patient has not menstruated one or more times, otherwise known as amenorrhea, it should be
considered a sign of AN. However, this is not a mandatory diagnostic criterion due to the fact
that some patients can be male, never had their period in the first place, or are post-menopause.
Laboratory testing can also be very telling about what is happening clinically with the
anorexia patient. The following lab work can be considered in determining the overall picture of
what may be happening with these patients:

Follicle stimulating hormone

Luteinizing hormone v. gonadotropin releasing hormone
IGF-1
Serum estradiol (low)

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Serum cortisol (high)

Urinary cortisol (high)
Albumin
SHBG
Nitrogen balance studies
Cholesterol (low)
Triglycerides
Glucose
BUN (low)
Hemoglobin/Hematocrit
Serum Fe
TSH
Electrolytes
Serum amylase (can indicated vomiting)
LFTs
Leptin levels
Ghrelin levels 7

There are many other clinical tests that can be indicated in the AN patient. Depending on
the case and the length of the disorder, it may be medically important to check for signs of longterm malnutrition. Often times in the clinical setting nursing can check for blood in stools and
monitor the input and output of the patient. MRIs, CT scans, and other tests can be used to scan
for ventricular enlargement from malnutrition. Patients with AN for more than 6 months and are
considered underweight should get a DEXA scan or a bone scan to determine if they have any
signs of osteopenia or osteoporosis. Limited estrogen exposure, consistent low body weight, and
long term amenorrhea can all contribute to poor bone density. Many deaths from anorexia are
from the cardiac arrhythmias that occur due to the severe electrolyte imbalances. This makes the
cardiologists role so important to the over treatment of the patient. Nursing can give EKGs and
work with cardiologists to monitor the vital signs of these patients to make the team aware of the
severity of the individual patients heart condition. 7
Physical Symptoms

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The most apparent and obvious physical symptom is weight loss. Reviewing growth
charts, weight trends, prior medical records, and the patients overall weight history is
imperative. There is no longer a set percentage of their ideal body weight required to get an
anorexia diagnosis however, it can be helpful to understand just how malnourished a patient
might be. It is also helpful in determining the weight goals to set for these patients to get them
back into a healthy weight range. Patients with consistent body weight below 85% of their ideal
can begin to suffer from amenorrhea, or missed menstruation, if they are women able to get their
periods to begin with. Its important to monitor the status and ask because complications from
amenorrhea can span into other medical problems in the long term.7
It is important to take notice of the persons skin; which can be very telling about the
patient. Looking for signs of lanugo, the downy layer of hair growth, as well as dry or chapped
skin can also indicate a problem. Yellow skin can indicate jaundice and liver problems associated
with rapid weight loss. Muscle wasting as well as loss of subcutaneous fat can show signs of
malnutrition. Temporal wasting, clavicle wasting, and overall poor skin quality can be a great
indicator of whats really happening medically even if the patient is downplaying their
symptoms. Checking patients extremities for edema can indicate fluid shifts and retention. This
would indicate electrolyte imbalances in the body. Often times patients suffer from hair loss and
can complain of brittle hair as well as nails. Checking a patients mouth for their dentition and
other oral health can show signs of purging. Dental decay, tooth loss, and poor gum quality are
all indicators of possible vomiting or poor nutrition overall. These are all physical signs that the
dietitian can notice while doing their assessment as well as if they are able to perform physical
assessments. 7

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Other symptoms can include edema, dehydration, orthostasis, syncope, generalized
fatigue, and insomnia. Most of these symptoms result from fluid shifts; and electrolyte
imbalances can come and go depending on the current state of the patient. Overall poor nutrition
and poor conditioning can contribute to the fatigue and lack of sleep. Each patient can have
multiple symptoms or just one or two of these complaints. Together many of these medical and
physical complications over time can cause severe, life-threatening situations for these patients.
Combine these patients lack of ability to see the severity of their circumstances with these very
daunting medical problems and the result can be very devastating.
Behavioral Symptoms
The behavorial symptoms of AN can vary greatly between patients but there are a few
common themes we see in this population. Amongst the most relevant is the immense fear of
weight gain. The patient believes there is never enough weight lost despite losing significant
amounts of weight. It becomes very difficult for the patient to grasp the severity of their illness.
They often have rigid thinking and refuse to believe, trust others. This can lead to denial issues,
trust issues within their social and family units, and can result in the patient being introverted.
Patients tend to withdrawal from their normal schedules, habits, family, and friends. They can
also have little tolerance for others or processes. Certain responsibilities can fall to the wayside
and their eating disorders responsibilities become most important. The combination and cycle of
these behaviors can result in suicidal ideations, depression, and extreme anxiety. 7
In the realm of nutrition, the patient typically refuses food or fluids, or both. They can
refuse all food or just restrict to certain foods. Sometimes AN patients have particular healthy
foods and unhealthy foods that they categorize and take diets to extremes. Patients can hide

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foods, pretend to eat, take smaller portions, or avoid even sitting down to eat altogether. Fluids
often become an issue for these types of patients because they either drink too much or too little.
Fluid-loading or filling up on water to keep a full feeling is common. On the opposite end of
the spectrum, some patients will refuse to drink any beverages as a means to avoid feeling full
and avoiding extra calories. Patients have to be evaluated individually to determine their own
eating and drinking behaviors so that the treatment team can address how they will treat them on
a personalized basis.
Another aspect of anorexia, depending on the type, can involve over exercising or an
obsession with burning the amount of calories taken in. Patients ritually need to exercise or go to
the gym. These behaviors can contribute to the person becoming even more malnourished and
can put them in danger of having even more problems with episodes of syncope, becoming
orthostatic, and putting their heart health at risk. There are also AN patients that can develop
addictions to diuretics, diet pills, supplements, or laxatives. It becomes ritualistic similarly to the
exercise addiction. These things can also cause problems with their health, as one can imagine,
with electrolytes and other micronutrients in the body. 7
The mood of these patients can change quickly and become a challenge when trying to
provide treatment. Mood swings and depression are common amongst this population. Its
helpful to be aware that these mood changes are not necessarily directed towards the care
provider and to be flexible in your methods to speaking with these patients. Separating the
person from the disorder is often the first steps to showing the patient you are trying to
understand their disorder.
Medical Complications

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The most common medical findings seen with AN include cardiac changes such as
murmur, orthostasis by pulse or by blood pressure, hypothermia, bradycardia, edema of
extremities with pitting, and slow capillary fill time. Fluid and electrolytes are going to be vital
in the monitoring of the AN patient as well. Screening patients lab values is very important in
the hospital setting. Oftentimes the symptoms of these abnormalities are overlooked as the
patient gets used to feeling weak and fatigued. In terms of sodium values, hypokalemia can be an
indicator that the patient partakes in behaviors like purging and laxative abuse. Hyponatremia
typically is seen with fluid overload, or patients who drink too much water. Hypoglycemia can
also occur in lower weight AN patients.8 Potassium may be low with overall malnutrition or
purging behaviors. Hyperkalemia may be present with dehydration. Chloride may be low from
purging or water loading behaviors. Bicarbonate will be elevated with vomiting. Phosphate may
be elevated with kidney function problems, excess Vitamin D, or healing stages of bone breaks.
Low phosphate is also present in malnutrition or increased glucose metabolism. Magnesium is
also low with fluid losses and high with dehydration. Hypocalcemia occurs with malnutrition or
use of laxatives. High calcium levels may be showing long-term diuretic use or bone fractures.
Liver function tests, cholesterol, amylase, lipase and hormone levels may also be seen in eating
disorder patients. 9
One of the most serious complications of anorexia medically is the effect starvation has
on your cardiac function. The fatigue associated with AN usually stems from the decreased
cardiac output. The cardiac muscle becomes weakened ultimately resulting in sinus bradycardia,
orthostatic hypotension, and systolic dysfunction. Due to these cardiac issues, its critical a
patient avoids caffeine and exercise. The body becomes used to the decrease in metabolic

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function and seems to adjust to the insufficient energy intake. These decreased metabolic
functions can also cause patients to experience hypothermia.
Table 1. Criterion of Cardiac Complications

Temperatures of <36.3C daytime or <36.0C

Hypothermia

overnight

Daytime heartbeat under 50 BPM and

Bradycardia

nighttime under 46 BPM

Systolic BP <90mm Hg or diastolic BP <45mm

Hypotension

Hg
Pulse increase of >35 BPM or BP decrease

Orthostasis

>10mm Hg

Re-feeding syndrome is a complication that occurs when the cardiovascular system fails
following high caloric intake in patients who are already compromised due to starvation and the
complications surrounding starvation metabolically become unstable. Re-feeding occurs when a
shift of phosphate from extracellular space to intercellular space causes phosphate to be
incorrectly incorporated into new tissues. This process in turn causes phosphate depletion in the
body systems resulting in little available ATP, poor cardiac stroke volume, and increased
demands on the cardiac muscle. By feeding a patient slowly, this should prevent re-feeding
syndrome from occurring but strict lab work monitoring is key. Sometimes a medical doctor will

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recommend a supplement to help with the increased phosphate needs during the initial week of
re-feeding. 8
The Academy of Nutrition and Dietetics recommends the following calorie progression in
those patients who are at risk for re-feeding syndrome:

Day One: 10 kcal/kg/day and 5 kcal/kg/day for those with BMI <14

Day Two-Four: Increase by 5 kcal/kg/day

Day Five-Seven: 20-30 kcal/kg/day

Day Eight-Ten 30 kcal/kg/day and increase as needed 9

Source:
http://www.oncoline.nl/index.php?
pagina=/richtlijn/item/pagina.php&id=36015&richtlijn_id=880

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Renal impairment is another serious concern with these patients. Despite patients having
normal creatinine levels, having low BMI and body weight put them at risk for poor renal
function. AN patients should receive urinalysis tests frequently to monitor electrolyte levels as
well to help determine renal function.
Eating disorder patients commonly can experience the following:

Transient azotemia (high nitrogen containing compounds)

Poor or decreased GFR, glomerular filtration rate

Periods of renal failure (rarely chronic renal failure, in serious cases)

Decreased concentrating ability 8

Table 2. Urinalysis Indications 8

Potassium less than 15meq/L

Indicates possible laxative abuse;

suggests extra-renal losses in the GI
tract; moderate hypokalemia

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Should this be with the chart on page 14

Potassium greater than or equal to

Severe hypokalemia; indicates possible

30meq/L

diuretic abuse

Ratio of urine sodium to urine

Indicator of bulimia or purging

chloride of greater than 1.16

tendencies

Gastrointestinal issues are very common in AN patients and is often one of the main
complaints of patients in recovery. Medications are often prescribed in the clinical setting to
help elevate some of these problems. However, GI problems can persist long after initial
refeeding and recovery depending on the individual. These things can elevate with weight
restoration and higher BMI. 8
Common GI Complications

Slowed GI motility

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Atypical hormonal function

Abnormal esophageal motor function

Nonstandard neurotransmitter function

Delayed gastric emptying/gastroparesis

Constipation

Bloating

Early satiety 8

Medical Treatment & Psychological Treatment

Effective treatment often requires more than just a trip to the hospital to get hydrated or a
month in outpatient rehabilitation. Long-term recovery means not only does the patient need to
be motivated but also the patients support system needs to be motivated as well due to the
complexity of treating this disorder. A multi-disciplinary approach is most often taken with these
types of patients. Mental health, nutritional stability, and medical wellness are all integrated in
the treatment of AN. Medical treatment often becomes priority as well as the reason many
patients seek initial help. Stabilizing the patient medically is also required before the patient can
be expected to be able to overcome any mental health issues. Depending on the type of
treatment, the patients demographics, and what is available to the patient there are many
different options for how to initiate recovery. However, in general, once a patient is treated in the
hospital setting for any emergent issues, most likely the patient will require either an outpatient
team or participating in a treatment program in order to receive the help they need.

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Family-based treatment or the Maudsley approach is an ideal way to treat eating
disorders in the adolescent population. This approach involves the support of the parents or
caregivers with an emphasis on weight restoration while the patient cannot be expected to do any
cognitive work while experiencing the effects of starvation. This method does not work for all
situations especially those here family abuse is present or the patients parents have their own
mental struggles. Traditional treatments focus on insight, motivation, and psychotherapy and
tend to be the typically treatment in the adult population. 16 There are many ways that the
traditional method can be installed and depends on what is available to the patient in your region.
No matter what the treatment method, food is ultimately going to be the medicine for these
individuals battling anorexia.

Medical Nutrition Therapy for Anorexia Nervosa

The Role of the Registered Dietitian
The Academy of Nutrition and Dietetics states the importance of the role of RD in the
treatment of anorexia as well as a part of the interdisciplinary team in their position paper on
eating disorders. Not only does the RD have to perform an appropriate nutritional intervention
that meets the individual needs of the AN patient but they have to maintain the professional
boundaries that are often needed when working with this population. It is imperative that the RD
has experience in eating disorders and an understanding of the psychodynamics that may be

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involved in the patients specific case. The knowledge of the nutritional aspect of anorexia will
provide the RD with the facts needed to provide the entire treatment team with a fitting treatment
plan. The RD can supply the treatment team with data from their nutrition assessments that may
be priority in keeping the patient medically stable. For instance, often times just seeing what a
patient is consuming in the hospital does not show what potential micronutrient deficiencies are
present. A proper food history obtained by the RD can predict what problems may need to be
addressed sooner than some lab work that does not always show imminent problems right away.
The RD also provides the role in treatment regarding the creation of normalized eating patterns
as well as understanding the life stages of growth with nutrition. All of these things combined
helps with RD hopefully promote weight gain, which tends to lead to better outcomes in this
population. 9

Nutrition Assessment
Assessing, monitoring, and evaluating the patient becomes even more challenging in
cases of anorexia. Obtaining a history and physical assessment is key to identifying the main
nutritional issues. Often this may need to be gathered from not only the patient but the patients
family as well. Depending on the type and co-morbidities surrounding the anorexia, the patient
may or may not be forth-coming to all of the symptoms they may be displaying. The age of the
patient will play a role as well. Be mindful that sometimes patients have been used to keeping
their disorder a secret and are capable of lying in regards to symptom use. Its imperative to use
what they report, what the family reports, and what their lab work may be indicating before

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making a final decision in their care. Keep in mind that there are serious consequences including
death in cases of co-morbidities that may increase suicidal ideation so any indicators of mental
distress need to be referred out to another specialty.
Beyond the RDs typical assessment tools used in the hospital setting, there are a few
questions to ensure you look into before completing an assessment on AN patients. The
following are assessment questions to touch on and information to obtain from patient or obtain
from history and physical:

Height/weight (may need nurse or doctor verification)?

Recent weight changes versus usual body weight? (Past 6 months, past year?)

Dietary intake or history (Whats a normal day for you?, Whats a typical
breakfast, lunch, dinner?)

Laxative or diuretic use?

Diet pill use or supplement use?

Ever binged or purged?

Last menstruation/dates?

Any other medical issues, co-morbidities?

Medications that could affect treatment?

Have you ever had a DEXA or bone scan? Results?

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Family history of eating disorders? 7

There are questionnaires and surveys that can be used to assess presence and severity of
anorexia. Typically, if in an interdisciplinary team setting, a psychologist or psychiatrist may be
the one using these psychological tests. The RD would have to be trained or have psychologybased education in order to distribute these tests accurately. The following are commonly used in
assessment:

PAQ or Parental Authority Questionnaire

EDI-2 or Eating Disorders Inventory-2

Perfectionism, compulsiveness tests

EAT-26 or Eating Attitudes Test 7

Intervention with the Anorexia Patient

The interventions are often very challenging in this specific population due to the fact
that the patients tend to be unrealistic of the severity of their illness to begin with. Attempting to
make such major lifestyle changes is difficult enough with someone who is willing to change;
nonetheless someone who is unable to see just how nutritionally compromised they are. The
patients motivation and overall willingness is going to play a major role in their outcomes. It is
imperative that the dietitian be willing to understand the fact that these interventions may be very

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uncomfortable and taxing for their patient. Making appropriate and reachable goals will assist in
this process.
The objectives of intervention on an anorexia patient, in regards to the dietitian:

Stopping the starvation process; which in turn allows physiological functions to

return to baseline

Promote weight gain based off growth rates, age, and normal patterns

Support psychotherapy/any potential needs for medication intervention

Monitor diet histories and food journals; look for any other potential issues such
as laxatives, diet pills, etc.

Honoring the presence of the illness; knowing there will be food rejection but
making normalized eating patterns a goal

Monitoring for re-feeding syndrome and fluid shifts by developing an appropriate

meal plan

Encourage normal menstruation if appropriate for the patient

Strive for the patient to gain self-esteem; create a new normal and avoid
preoccupations with food, weight, numbers, calories, etc.

Be aware of co-morbidities and the need for interdisciplinary members help

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Make nutrition education, therapy, and planning a part of the treatment teams
main concern 7

Caloric Needs
Typically the dietitian will use all of their information available; and based off of
the growth rate, age, IBW, UBW, and all other pertinent weight data will determine the best goal
weight for the patient. It can be useful to set small goals for the patient as it can be overwhelming
to use the final weight goal in the counseling setting. Estimating caloric needs for AN patients
has been set by the APA, or the American Psychiatric Association, use the following guidelines
unless otherwise set by your facility:

Initial intake should be 30-40 kcal/kg which totals 1,000-1,600 kcal/day

Increase needs slowly to meet goals; avoid re-feeding syndrome

Promote weekly weight gain; 1-2lbs or 2-4lbs per week are normal goals

Some patients may require up to 70-100 kcal/kg to gain weight

Typical weight maintenance is 40-60 kcal/kg to maintain weight 7,10

Macronutrient Needs & Micronutrient Needs

Macronutrient needs in anorexia patients are not going to be met during their disease
state. Some patients will restrict certain foods or food groups, while others just restrict calories.
The evaluation of macronutrient needs is going to be individualized for you patient but being

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aware of common medical problems associated with restriction of certain macronutrients will be
helpful in your treatment of the patient.
Table 3. Macronutrient Associated Concerns 11
Glucose Metabolism: hypoglycemia is

Renal Impairment: Urea and creatinine are

commonly seen in this population; often well-

normally low in this population due to

tolerated by patients can be undocumented

decreased intakes; however, if elevated levels

symptoms; severe hypoglycemia should require

or near to high levels can indicate dehydration

medical attention

or impaired renal function

Lipid Abnormalities: high cholesterol is

Serum Protein: usually normal in AN patients;

common among AN patients; will improve with

if low consider possible infection; if albumin is

recovery; uncertain if this plays a role in

low and there is no infection present, outcomes

cardiovascular risk or just a symptom of the

are usually poor for the patient; check

disease state

prealbumin and trend with C-reactive protein

to look for inflammation

Micronutrient needs are likely not met in the anorexic population. Sometimes these
micronutrient deficiencies are challenging to assess because of their blood concentrations versus
whole-status may be varied. However, it is imperative to be able to identify the common
deficiencies since in general they are more at risk than the regular population. Common
deficiencies are listed below, and are usually treated by use of a multivitamin or dietary
supplement in this population:

Zinc

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Copper

Vitamin C

Riboflavin

Vitamin B6

Thiamin 11

Goals and Monitoring

As the dietitian it is going to be essential to the recovery of the patient to set obtainable
goals. Promoting healthy eating patterns along with normalizing nutrition are going to help
encourage weight gain in the patient. Typical ways to monitor and evaluate include intake
records or food journals, improving weight and height for age, improved body image, decreased
anxiety around meals, and overall feeling out where the patient is with discussion about their
perceptions of recovery. 11
Recovery is not a quick and easy task but a lifelong battle for most anorexia patients.
Many families and caregivers are going to need education beyond the medical complications to
understand the struggle of their loved-ones with anorexia. Weight restoration is the best predictor
of outcome we have at this point. It is unclear if this means the patient can tolerate long term
recovery and weight maintenance or if they will fully recover. 12
The ideal ways we can treat eating disordered patients as dietitians is to promote and
encourage healthy weight, normalize eating patterns, and be a constant reminder of how nutrition
keeps our bodys functioning at their best.

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Supplementation versus Nutrition Support
There are some cases where patients are going to need caloric help beyond the beginning
of normalized eating patterns. There are also settings where it is just as important to initiate some
form of nutrition support in the patient. Many times in a hospital setting eating disorders get
overlooked as a serious medical concern for a combination of reasons. 13 It is important for the
RD to be aware that these types of patients often fall through the cracks in the hospital setting. It
is imperative to be familiar with the signs and symptoms of eating disorders so that it is easier to
spot these patients in the hospital or clinical setting.
If a patients capable of weight restoration without nutrition support then that should be
the ideal situation. Gradual caloric increase orally is best. Some patients struggle with the
amount of food needed to meet their goal caloric needs. In these cases, added nutritional
supplements, like Ensure Plus, for example, are typically used. However, some patients need
more than just the added calories from a nutrition supplement but need nutrition support in order
to gain weight. Patients who refuse to eat sometimes are offered nasogastric tube feedings to help
supplement their intakes. TPN is typically not indicated, as gastrointestinal function is likely
intact with these patients. Preserving gut function will be beneficial to the patient in the long run
even though they may suffer from gastrointestinal discomfort with the re-feeding process. TPN
therefore is usually a last resort. The ultimate goal is restoring normalized eating patterns so
prolonging this makes recovery oftentimes longer and more difficult. With that being said, there
are cases where anorexia patients with gastrointestinal co-morbidities have needed total
parenteral nutrition or TPN in order to meet their needs. 14 Use caution before initiating TPN
with anorexia patients and trust your clinical judgment in these situations.

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Presentation of the Patient

Patient Admission Data
Initials: CH

Admit Weight: 95 lbs

or 43.2 kgs

Highest
Weight/When?: 127#
in May of 2014

Weight Hx Over Past 6

months: 30# in last 6
months

Age: 25

BMI: 14.7

Lowest
Weight/When?: 92# in
November 2014

Allergies/Food
Allergies: NKFA;
noted seasonal
allergies

Height: 67.5 inches or

57

IBW: 137#

Percent IBW: 69.1%

Family Hx of ED?: No
family hx of EDs

IBW +/- 10%: 124151#

Residential Treatment Course

Date of Admission/Reported Motivation: 11/28/14
CHs admission was scheduled into inpatient residential treatment at the Renfrew Center of
Philadelphia. It was a voluntary admission into treatment for her eating disorder. Pt is familiar
with the program but meets with financials, nutrition, psychology, psychiatry, nursing, and a
nurse practitioner. Pt states, I am sick and tired of being sick and tired. Pt rates motivation
level on scale of 1-10, 1 being not at all, 10 being 100% motivated. Pt reports 8-9 during
interview. Pt reports she is miserable with her life with AN.
History of Illness/Past Medical History: 25-year-old female, previous admission to Renfrew in
February 2014, with anorexia for the past 2 years or so. Pt reports struggling with depression

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throughout her adult life but is on medication. Pt has had no hospital admissions at this point but
has lab work on admission with low BUN. Pts BMI is 14.7, and is 95# upon admission. Pt
presents with 32# undesirable weight loss since May 2014. Pt noted alert and pleasant during
initial assessment. Pt reported high motivation for recovery. Pt reports doing well initially after
last admission, where she left at within 90% of her IBW. However, things have gone down hill
since a bad relationship over the past spring/summer.
Current Diagnosis: AN, depression
Social History: Pt does not smoke, drinks wine socially without reported alcohol abuse, no
noted drug abuse. Pt states being in a difficult relationship over the summer and has been
struggling since. There is some question into whether the man she was in the relationship with
was harassing her or if she was struggling with letting go of the relationship. At this time she is
in a new relationship for approximately 2-3 months. Pt reports she recently shared with her new
boyfriend about her AN. He is open to participating in her recovery process. Pt states he is going
to be doing family therapy with her instead of her parents since she no longer lives at home. Pt
lives with a cousin at this point and has no notable problems with her.
Family History: Reports no notable family hx with illness, no family with eating disorders. Pt
states she has an okay relationship with parents.
Medications at Home: Zoloft, Multivitamin
Medications at Renfrew: Zoloft 100mg 1x/day, Zyrtec PRN, MVI daily, Tums/Calcium daily,
Colace PRN

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Initial Nutrition Assessment

Eating Disorder Symptom Questionnaire with Patient Responses:
Restricting? Daily recently, on and off since June 2013/ last used symptom day prior to
admission
Bingeing? Never
Purging/Vomiting? Never
Laxative use? Never
Diuretics/Diet Pills/Ipecac? Never
Chewing/Spitting out food? Never
Exercise? 2013-2014 has attempted to exercise within normal limits however, reports she
was unable to maintain enough energy to exercise regularly; past history of over-exercise
ETOH abuse? Pt reports only drinking socially
Water consumption? 3-4 cups per day
Coffee/Tea? 1 cup of regular per day; denies abuse
Diet soda? 1 16oz bottle a day
Gum or hard candy? 1-2 packs of gum per day

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Average reported calorie intake? ~500 kcals per day; pt reports trying not to count
calories but is aware

Dietary Recall: Sample Day:

B: Yogurt 1 cup; usually vanilla
L: Salad with no dressing, red wine vinegar 1 tsp., variety of vegetables, maybe some
grilled chicken
D: Sushi *only 3 pieces*, handful of edamame, plain salad on side

Medical Symptom Questionnaire with Patient Responses:

Last menstrual period? Diagnosis of Amenorrhea? LMP in May 2013, yes, medical
diagnosis of amenorrhea
Constipation/Diarrhea? Not recently, no GI complaints
Dizziness/Lightheaded? Not at this time
Osteopenia/Osteoporosis dx? Reports no DEXA scan yet, is going to schedule outpatient
Other Pertinent Information:

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Living Situation Currently/Plans for Discharge? Lives with cousin in an apartment, plans
on living with cousin after discharge
Previous admissions from anorexia? Inpatient treatment at Renfrew in February 2014,
day treatment post inpatient. Reports check ups regarding medical status at PCP
regularly. Seeds of Hope treatment in 2014 as well.
Fear foods? Anxiety around most foods except vegetables; biggest fears are
starches/carbohydrates, dairy, and will not eat red meat
Food rituals? None reported
Do you weigh yourself? Reports she weighs herself daily in the morning on MondayFriday, not on weekends
Calorie Needs: (Adult REE using Mifflin St. Jeor x 1.3-1.5) 1209 x 1.3-1.5= 1571-1814 kcals +
anabolic needs (+500-1000)= 2571-2814 kcals
Protein Needs: (1.8g x kg) 43kg x 1.8= 77 gm protein/day
Fluid Needs: (kg x 35mL) 43kg x 35= 1505 mL or 50 oz or 6 cups water/day
PES: Inadequate oral intake related to disordered eating as evidenced by BMI 14.7, ~500
kcals/day, and 32# weight loss over 6 months.
Nutrition Prescription: Meal Plan A (1500-1800 kcals) with an automatic increased to Meal Plan
B (1800-2100 kcals) after 2 days post admission; 360 kcal supplement for weight loss daily or
restriction of current meal plan (1 can Ensure Plus for >50% of meals, 2 cans of Ensure Plus for
<50% of meals)

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Intervention: Initiate standard meal plan progression with additional calories/supplements;
provide supportive meal environments with support level dining for at least 3 days meal
completion
Nutrition Goals:

Meet nutritional needs with compliance of meal plan prescribed

Accept meal plan adjustments and added supplements as indicated
2-4# weight gain per week
Maintaining normal lab work with prevention of re-feeding syndrome

Monitor and Evaluation:

Food Journals/Meal Compliance Records

Daily weights/vital signs
Labs and Urinalysis
Plan of care/Treatment Plan

Table 4. Nutrition Plan Sheet Throughout 1st Month of Admission

Date
Time

Meal Plan and Meal Level Changes

12/2/14
12/3/14

Increase MP to B+1 snack @ 3pm (~2300 kcals)

Increase MP to B+2 snacks (~2600 kcals)

12/5/14

Increase MP to B+2 snacks+1 supplement (~2950 kcals)

12/12/14 Increase MP to B+ 2 snacks +2 supplements (~3300 kcals)

12/15/14 Increase patient to interdependent dining level today. Pt will be able to fix her own
portions & pick menus in the moment.
12/16/14 Increase MP to C+ 2 snacks + 2 supplements (~3500 kcals)
Followed pt for one month only, pt discharged February 2015** MP increases continued until

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goal weight was met within 90-95% IBW

See Appendix for Weight Trend Documents Over 1st Month, Pictures 1, 2, 3*

Table 5. Basic Metabolic Panels Over December 2014

BMP/Dates

11/28

12/2

12/5

12/9

12/17

66

70

75

74

6L

10

13

13

.74

.67

.67

.71

138

140

141

141

4.1

4.2

4.2

99

103

104

103

(Reference Range)

Glucose
65-99mg/dL
BUN
7-25 mg/dL
Creatinine
.50-1.10 mg/dL
Sodium
135-146 mmol/L
Potassium
3.5-5.3 mmol/L
Chloride
98-110 mmol/L

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Carbon Dioxide

25

26

27

30

10.2

9.8

10

10.1

2.3

2.3

3.7

3.7

4.0

4.8 H

5.4 H

19-30 mmol/L
Calcium
8.6-10.2 mg/dL
Magnesium
1.5-2.5 mg/dL
Phosphate/Phosphoru
s
2.5-4.5 mg/dL

See Appendix for Initial Urinalysis & Drug Screen Pictures 4, 5*

Follow Up Nutrition Assessment 12/19/2014

Follow-up on problem: Inadequate oral intake
Diet: Meal plan C+2 snacks +2 supplements since 12/17
Assessment: Pt is somewhat flat. Reports she is being 100% compliant but is frustrated
since she feels she is doing everything and her meal plan keeps increasing. Pt states her
boyfriend coming to therapy is helping her realize he needs to be a part of her recovery
and help her with meals at home. Pt feels guilty that he has to be a part of recovery
however. Pt reports she is okay with gaining weight and knows it is a part of it but has
been feeling uncomfortable. Pt is up 9.7 # since admission at this point and reports

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gaining the weight is not a problem for her, it is maintaining once she is in her home
environment.
Estimated Needs: Pt likely in a hyper metabolic state at this point in treatment, now 47.6
kg, will require increased needs to meet weight goals.
47.6 kg x 35 kcals=1666 x 1.8 = ~3000 + (500-1000 for anabolic state) = ~3500-4000
kcals; Meal Plan C+ 2 snacks + 2 supplements = ~ 3500 kcals
Nutrition Prescription: Will continue Meal Plan C (2100-2400 kcals) + 2 snacks per day
of her choice from options available (~350-400 kcals each) + 2 Ensure Plus (350 kcals
each)
Updated PES Statement: Increased energy expenditure related to history of anorexia
nervosa as evidenced by hyper metabolic state and increased calorie needs to gain
weight.
Intervention:

Continue increased meal plan to promote 2-4# weight gain per week

Allow exercise programming at intermediate level as pt meet weekly weight goals

Patient will follow new weighing schedule 3x per week instead of daily

Goals:
Continue 2-4# per week gain towards weight goal of + or 10% of IBW
Attending exercise program at Renfrew to normalize habits
Accepting of 3x per week weights instead of daily weights with decreased anxiety
Monitor and Evaluate:

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Monitor Phosphorus labs with nursing/CRNP

Acceptance/tolerance to supplements/snacks
Exercise group attendance
Weekly weights
Plan of care/treatment plan

Critical Comments
Residential treatment is very different from the clinical hospital setting in regards to your
role as a registered dietitian. The RD sees their patients and gets to know them more in depth due
to the increased length of stay and increased number of sessions. The are looking at the patients
status daily and can make adjustments to their meal plans more frequently since they are
observing them day to day. Their sessions consist more of nutritional counseling than a brief
check in and education you would be getting in the hospital. This allows for more individualized
care with the patient. In the clinical setting of a hospital one may only see the patient a few times
and it may not be the main objective for the anorexia patient to meet weight gains so much as to
be stabilized. The other major challenge I had was that in inpatient treatment like Renfrew, the
nursing staff and CRNP oversee lab work and abnormalities. The RD in this setting has little say
in medications and recommendations in regards to supplements as theyre as pre-established
protocols for this population. All of these things made it a bit more difficult for me to apply my
clinical knowledge from being in the hospital setting to this case study.
It was also taxing for me that I was not able to take on the role of the RD more in CHs
case study, as I was not at Renfrew on a daily basis. The fact that they do not have an established
electronic medical record also made it complicated when I was at Renfrew, as I had to track
down a paper chart and decipher handwriting. The staff at Renfrew was extremely helpful in
helping me with what questions I did have since I was not able to be there daily. I was able to

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check in multiple times over the three months CH was there. Overall, I feel like I had an eyeopening experience getting to work on my case study at Renfrew because it showed me just how
different the role of the RD could be from setting to setting.

Summary
As CH was not in the hospital setting I have been completing my dietetic internship at, it
was challenging to continue gathering information on her complete treatment course. However,
after speaking with nursing, nutrition, and other clinical areas at Renfrew this past February, CH
continued to gain weight and meet her weight goals during her second stay in treatment. CH
attended family therapy with her boyfriend and was compliant with attending groups as
scheduled for her. CH was the type of patient that was a people-pleaser so her challenge was
not completing the program but just how to implement recovery into her daily life. CH
discharged after reaching her goal weight and was planning on continuing treatment in the day
treatment setting. She attended the exercise program as well as cooking groups and the grocery
store outing with her team members. In total she was at Renfrew for about three months. CH
was planning on attempting to go back to complete her Masters Degree which she was never able
to finish with her AN being a distraction. She also was hoping to take more serious steps in her
relationship with her boyfriend upon leaving Renfrew.
It is often challenging for young adults to make recovery work with an ever changing
lifestyle as they enter the working world, begin families, and are trying to make relationships
last. For CH, my hope is that she can make recovery work for her with or without a boyfriend or
her family, as they may not be supportive forever. CH is lucky that her AN started later in life

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and was not a long seeded disease state; I hope that she has a lifetime of memories of health prior
to the recent AN that she will be able to modify her behaviors to better her life in the long term.

Terminology
AN-anorexia nervosa
Azotemia- high levels of nitrogen containing compounds in the blood; elevated BUN/Creatinine
levels
Bradycardia- resting heart rate under 60 beats per minute in adult populations
Glomerular Filtration Rate- a lab test that checks how well the kidneys are functioning by
assessing how much blood will pass through each glomerulus each minute
Ghrelin-hormone that triggers hunger
Leptin-hormone that reduces hunger
Orthostatic hypotension-low blood pressure that can occur from sitting/laying to standing with
symptoms of light-headedness or dizziness; sometimes fainting can occur in severe cases
Tachycardia-faster than normal heart rate while at rest; adult heart rates are typically 60-100
beats per minute

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Medication Bibliography

Medication
Zoloft

Generic Name
Setraline

Indications
Anti-depressant
or selective
serotonin
reuptake inhibitor
(SSRI)

Contraindications

Food
Interactions

Avoid alcohol
Can cause
weight changes;
must monitor
for weight loss

Hyponatremia

Impaired renal
function

Colace

Docusate

Stool softener

N/A

N/A

Tums

Calcium
Carbonate

Prevention or
treatment of
calcium
deficiency

N/A

N/A

*Other medical
treatments may be
indicated-Example:
reducing stomach
acid

Zyrtec

N/A

Cetirizine
hydrochloride

Generic
Multivitamin

Antihistamine

Supplementing
vitamins/minerals
lacking in the

Impaired liver
or renal
function

Use caution
with sedatives

Avoid over
supplementatio

Avoid alcohol

Take separately
from calcium

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diet

Appendix
Picture 1.

Picture 2.

supplement

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Picture 3.

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Picture 4.

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Picture 5.

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References
1. Wade T D, Keski-Rahkonen A, Hudson J. Epidemiology of eating disorders. New York,
NY: Wiley; 2011. Pg 343-360.
2. Get the facts on eating disorders. NEDA. http://www.nationaleatingdisorders.org/getfacts-eating-disorders. Accessed December 10, 2014.
3. Arcelus J, Mitchell A J, Wales J, Nielsen S. Mortality rates in patients with anorexia
nervosa and other eating disorders. Archives of General Psychiatry; 68(7): 724-731.
4. Feeding and eating disorders. American Psychiatric Association.
http://www.dsm5.org/documents/eating%20disorders%20fact%20sheet.pdf. Published
2013. Accessed December 10, 2014.
5. Types and symptoms of eating disorders. NEDA.
http://www.nationaleatingdisorders.org/general-information. Accessed December 12,
2014.
6. Diseases & Conditions: Anorexia Nervosa. The Mayo Clinic.
http://www.mayoclinic.org/diseases-conditions/anorexia/basics/tests-diagnosis/con20033002. Updated December 30, 2014. Accessed January 10, 2015.
7. Escott-Stump S. Nutrition and Diagnosis-Related Care, 7th edition. Philadelphia, PA:
Lippincott Williams & Wilkins, a Wolters Kluwer business; 2012. pg 266-268.
8. Mehler P, Krantz M. Anorexia nervosa medical issues. Journal Of Women's Health. May
2003; 12(4): 331-340. Available from: CINAHL Complete, Ipswich, MA. Accessed
February 15, 2015.
9. Nutrition Intervention in the Treatment of Eating Disorders. Eat Right: The Academy of
Nutrition and Dietetics. http://www.eatrightpro.org/resource/practice/position-andpractice-papers/position-papers/nutrition-intervention-in-the-treatment-of-eatingdisorders. Published August 2011. Accessed December 12, 2014.
10. American Psychiatric Association. Treatment of patients with eating disorders, third
edition. American Psychiatric Assocation. Am J Pyschiatry. 163: 4S, 2006.
11. Winston A. The clinical biochemistry of anorexia nervosa. Annals Of Clinical
Biochemistry. March 2012;49(Pt 2):132-143. Available from: MEDLINE with Full Text,
Ipswich, MA. Accessed January 19, 2015.
12. Lund B, Hernandez E, Yates W, Mitchell J, McKee P, Johnson C. Rate of inpatient
weight restoration predicts outcome in anorexia nervosa. The International Journal Of
Eating Disorders. May 2009;42(4):301-305. Available from: MEDLINE with Full Text,
Ipswich, MA. Accessed January 19, 2015.

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13. Powers P, Cloak N. Failure to Feed Patients With Anorexia Nervosa and Other Perils and
Perplexities in the Medical Care of Eating Disorder Patients. Eating Disorders. January
2013;21(1):81-89. Available from: Academic Search Complete, Ipswich, MA. Accessed
January 18, 2015
14. Mehler P, Weiner K. Use of total parenteral nutrition in the refeeding of selected patients
with severe anorexia nervosa. The International Journal Of Eating Disorders. April
2007;40(3):285-287. Available from: MEDLINE with Full Text, Ipswich, MA. Accessed
January 18, 2015.
15. Katzman D, Misra M. Bone health in adolescent females with anorexia nervosa: what is a
clinician to do? The International Journal Of Eating Disorders. July 2013;46(5):456-460.
Available from: MEDLINE with Full Text, Ipswich, MA. Accessed January 18, 2015.
16. Heckert KB. Family-based treatment: getting parents involved in the outpatient treatment
of eating disorders. Scans Pulse. Winter 2014: 33 (1): 12-14.