Melissa has just been admitted to an inpatient hospital unit. She is 19 years old and reports the onset of anorexia nervosa at 12 years of age. Upon admission, Melissa’s weight is 68 lb, and her height is 61 inches. Patient began menses early at the age of 11, and because of adolescent developmental changes reported feeling uncomfortable in her body. At this time she was 58 inches and weighed 100 lb (between 50th and 75th percentile). She learned she could restrict through seeing her mom diet at home and began counting her calories. She would aim for less than 1000 calories per day and began walking for 30 to 60 minutes daily. After 6 months, halfway through her sixth grade year, Melissa had dropped to 82 pounds and did not grow in height during this time; she remained at the 25th percentile and stopped menstruating. Melissa’s parents began worrying and started to adapt a Maudsley/family-based therapy approach of eating at home in which she ate all of her meals at home with them. She would continue to restrict at school and exercise as much as she could. By the age of 17 Melissa had gained back some weight and graduated from high school, weighing 105 lb with a height of 62 inches (10th percentile for weight and 10th to 25th for height). After her first year away at college, Melissa began restricting again, this time down to approximately 500 calories per day. Her typical daily intake now is 1 cup coffee in the morning with an apple. For lunch she has salad from the dining hall with 3 ounces of sliced turkey on it and a ½ cup of brown rice with balsamic vinegar. For dinner she has two pieces of laughing cow cheese with steamed vegetables from the dining hall. If she gets hungry at night, she will have an individual bag of fat-free popcorn. She also reports 60 to 90 minutes of walking or running per day around campus or at the gym. Since her first onset of menses, Melissa was getting her period on average 2 to 3 times per year. It has now been 1 year since her last period (age 18). Melissa denies any purging or laxative abuse. Since being in the hospital, Melissa has struggled with eating 100% of her planned meals. She reports fearing any foods high in fat such as cheese, fried foods, desserts of any kind, meat, oils, and potato chips. Melissa is refusing to drink regular milk as well. The nursing staff on the unit told you that Melissa has been consuming approximately 50% to 60% of her 1800 kcal meal plan and has not taken any of the recommended supplements.
Medical history: amenorrhea, hypokalemia Current medications: MVI with trace minerals, thiamine daily Inpatient calorie prescription: 1800 kcal/day B/P: 89/58 Pulse: 58 Laboratory Values:
Nutrition Diagnostic Statement
Underweight related to abnormal eating pattern as evidenced by a restrictive caloric intake and excessive exercise in the setting of being below 75% IBW.
Questions
1. List the essential criteria for the diagnosis of anorexia nervosa.
2. What are some behavioral or psychologic treatment approaches that could be used to help Melissa?
3. What are the significant physical findings from a nutrition-focused physical examination of Melissa? What are some other symptoms commonly seen in anorexia nervosa?
4. Assess Melissa’s laboratory values and indicate what other values also may be altered in her condition.
5. What is Melissa’s goal weight? How would you calculate that?
6. What are some typical reasons why Melissa may be avoiding food and losing weight?
7. What are common complications to assess for when monitoring refeeding syndrome?
8. What would be a safe and appropriate rate of weight gain for Melissa in the inpatient hospital setting?