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+ MNT in a Residential Eat Disorder Treatment Facil Aly Brown Sodexo Dietetic Internship July 30, 2013
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Page 1: + MNT in a Residential Eating Disorder Treatment Facility Aly Brown Sodexo Dietetic Internship July 30, 2013.

+

MNT in a Residential Eating Disorder Treatment Facility

Aly BrownSodexo Dietetic Internship

July 30, 2013

Page 2: + MNT in a Residential Eating Disorder Treatment Facility Aly Brown Sodexo Dietetic Internship July 30, 2013.

+Purpose

Explore the psychological and physical intricacies of EDs

Large part of treatment is nutrition

What is the role of the RD?

Page 3: + MNT in a Residential Eating Disorder Treatment Facility Aly Brown Sodexo Dietetic Internship July 30, 2013.

+Agenda

I. Eating Disorders Classifications Causes Prevalence Treatment Recovery

II. Anorexia Nervosa

III. Medical Nutrition Therapy

IV. Presentation of Patient

V. Summary

Page 4: + MNT in a Residential Eating Disorder Treatment Facility Aly Brown Sodexo Dietetic Internship July 30, 2013.

+Background Information

Eating Disorder (ED) Classifications: Anorexia Nervosa (AN) Bulimia Nervosa (BN) Binge-Eating Disorder (BED) Eating Disorder Not-Otherwise-Specified (EDNOS)

Diagnostic criteria established by American Psychiatric Association (APA); criteria published in Diagnostic and Statistical Manual of Mental Disorders (DSM)

Page 5: + MNT in a Residential Eating Disorder Treatment Facility Aly Brown Sodexo Dietetic Internship July 30, 2013.

+Potential causes

Neurochemical and psychological disorders Anxiety disorders (most prevalent)

Genetics

Interpersonal Physical or sexual abuse

Sociocultural Media, peers

Page 6: + MNT in a Residential Eating Disorder Treatment Facility Aly Brown Sodexo Dietetic Internship July 30, 2013.

+Prevalence

~24 million people

1 in 10 receive treatment

Highest mortality rate of any mental illness

Page 7: + MNT in a Residential Eating Disorder Treatment Facility Aly Brown Sodexo Dietetic Internship July 30, 2013.

+Treatment

Hospital, residential treatment facility, or private office

Inpatient Cornerstone for ED treatment

Outpatient• Medically stable to be discharged from an inpatient setting, yet still

requires structure to continue with treatment

• DTP, PHP, IOP

Page 8: + MNT in a Residential Eating Disorder Treatment Facility Aly Brown Sodexo Dietetic Internship July 30, 2013.

+Pharmacological Treatment

Fluoxetine (Prozac) used for BN Only FDA approved medication for treatment of ED SSRI often used for depression Not a cure; alleviates some of the symptoms

No pharmacological evidence for AN

Medications only indicated in severe circumstances

Must be used in combination with psychotherapy

Page 9: + MNT in a Residential Eating Disorder Treatment Facility Aly Brown Sodexo Dietetic Internship July 30, 2013.

+Non-Pharmacological Treatment

Psychotherapy Family-based treatment (FBT) Cognitive behavior therapy (CBT)/ Behavior Therapy (BT) Dialectical behavior therapy (DBT)

Medical

Nutrition

Alternative (Yoga, spirituality, religion)

Page 10: + MNT in a Residential Eating Disorder Treatment Facility Aly Brown Sodexo Dietetic Internship July 30, 2013.

+Recovery

Not instantaneous

Facilitated with long-term treatment

Stages of change:

Page 11: + MNT in a Residential Eating Disorder Treatment Facility Aly Brown Sodexo Dietetic Internship July 30, 2013.

+Anorexia Nervosa

DSM-5 Criteria for Diagnosis: Not maintaining normal weight for

age and height Intense fear of gaining weight or

being overweight Disturbance in body weight or shape Denial of the seriousness

Page 12: + MNT in a Residential Eating Disorder Treatment Facility Aly Brown Sodexo Dietetic Internship July 30, 2013.

Perfectionist

Dependent

Obsessive-compulsive

Meticulous Fear of growing up

Introverted

Trust issues

Overly rigid thinker

Socially insecureSelf denying

Characteristics of AN

Page 13: + MNT in a Residential Eating Disorder Treatment Facility Aly Brown Sodexo Dietetic Internship July 30, 2013.

+Warning Signs

Dramatic weight loss

Preoccupation with weight or food

Refusal to eat certain foods

Excessive exercise

Withdrawal from friends and activities

Development of food rituals

Page 14: + MNT in a Residential Eating Disorder Treatment Facility Aly Brown Sodexo Dietetic Internship July 30, 2013.

+

Physical

Lanugo

Brittle nails

Thinning hair, falls out easily

Muscle wasting

Blotchy, yellow skin

Consequences

Internal

Cardiac complications

Reduced bone density

Growth retardation

Amenorrhea

Digestive dysfunction

Psychological

Anxiety

Depression

Social withdrawal

Irritability

Food fixation

Page 15: + MNT in a Residential Eating Disorder Treatment Facility Aly Brown Sodexo Dietetic Internship July 30, 2013.

+Minnesota Starvation Study

Association between psychological disturbances and starvation

Subjects developed AN-like thoughts and behaviors

Psychological disturbances disappeared when re-nourished

Page 16: + MNT in a Residential Eating Disorder Treatment Facility Aly Brown Sodexo Dietetic Internship July 30, 2013.

+Hormonal adaptation in AN

Page 17: + MNT in a Residential Eating Disorder Treatment Facility Aly Brown Sodexo Dietetic Internship July 30, 2013.

+Medical Nutrition TherapyIn a Residential Eating Disorder Treatment Facility

Page 18: + MNT in a Residential Eating Disorder Treatment Facility Aly Brown Sodexo Dietetic Internship July 30, 2013.

+Role of the Registered Dietitian (RD)

Main Goals: Weight restoration Determine target weight Determine energy needs Customize a healthy eating plan Correct disordered thoughts about food and eating

Well supported as an essential component of treatment

Collaborate with multi-disciplinary team

Page 19: + MNT in a Residential Eating Disorder Treatment Facility Aly Brown Sodexo Dietetic Internship July 30, 2013.

+Where to start

Take focus away from calorie counting

All nutrition prescriptions are individualized

Educate

Identify possible barriers

Motivational Interviewing

Encourage and applaud minute accomplishments

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+

Page 21: + MNT in a Residential Eating Disorder Treatment Facility Aly Brown Sodexo Dietetic Internship July 30, 2013.

+Nutrition Screening

Clinical indicators for ED risk Unintentional weight loss

≥5% in one month ≥10% in 1-6 months

Unintentional weight change ≥ 10% in the past 3 months Decreased appetite < Half usual food intake in past 7 days

Mini Nutritional Assessment to assess for malnutrition

Page 22: + MNT in a Residential Eating Disorder Treatment Facility Aly Brown Sodexo Dietetic Internship July 30, 2013.

+AssessmentPatient History Reason for seeking care

Medications

Supplement or vitamins

Menstrual history

ED related treatment history

Chronic disease states

Family health history

Oral health history,

Psychiatric history

Socioeconomic status

Living situation

Social and medical support

History of recent crisis

Activity level

Meal preparation.

Religious or cultural dietary practices

Alcohol or drug use/abuse

Page 23: + MNT in a Residential Eating Disorder Treatment Facility Aly Brown Sodexo Dietetic Internship July 30, 2013.

+AssessmentFood and Nutrition-Related History

Food habits (rituals, preoccupations)

Eating patterns

Restrictions and “fear foods”

Preferences

Intolerances/allergies

Obtained by: 24-hour recall, food

frequencies, or food records

Page 24: + MNT in a Residential Eating Disorder Treatment Facility Aly Brown Sodexo Dietetic Internship July 30, 2013.

+ AssessmentLaboratory Data and Procedures

Mandatory:

Electrolytes

EKG

Complete blood count with differential

Blood urea nitrogen (BUN) and creatinine

Blood glucose

Calcium

Liver function tests

.

Optional Cholesterol

Thyroid function tests

Chest or abdominal X-rays

Electromyography (EMG)

Examination of muscle enzymes (CPK)

Computed tomography (CT)

GI endoscopy

Magnetic resonance imaging (MRI)

scans of the head

Body Composition

Page 25: + MNT in a Residential Eating Disorder Treatment Facility Aly Brown Sodexo Dietetic Internship July 30, 2013.

+Nutrition-Focused Physical Assessment

Page 26: + MNT in a Residential Eating Disorder Treatment Facility Aly Brown Sodexo Dietetic Internship July 30, 2013.

+Anthropometric Data

Weight

Height

BMI

Page 27: + MNT in a Residential Eating Disorder Treatment Facility Aly Brown Sodexo Dietetic Internship July 30, 2013.

+Diagnosis

Sample PES statement

Inadequate oral intake related to limited food acceptance due to

psychological issues as evidenced by weight less than 75% ideal body

weight and food recall consumption meeting less than 25% calorie needs

Diagnosis may be hard to accept for many patients

Page 28: + MNT in a Residential Eating Disorder Treatment Facility Aly Brown Sodexo Dietetic Internship July 30, 2013.

+Intervention

Should target the problem decided upon from diagnosis

Nutritional intervention should be timely and appropriate

Immediate interventions: Determining target weight Developing nutrition prescription

Page 29: + MNT in a Residential Eating Disorder Treatment Facility Aly Brown Sodexo Dietetic Internship July 30, 2013.

+InterventionDetermining Target Weight

Adolescents CDC growth curve charts

BMI McLaren method Moore method

Use previous height/weight percentiles IBW calculation Resumption of menses Highest pre-ED weight

Weight goal for adolescents is often a moving target!

Page 30: + MNT in a Residential Eating Disorder Treatment Facility Aly Brown Sodexo Dietetic Internship July 30, 2013.

+InterventionNutrition Prescription

Calories: REE x AF (1.2-2.0) 40-50 calories per kilogram + 500 calories for anabolic energy

needs Begin with:

600-1,000 calories per day Advance by:

300-400 calories every three to four days May need up to 4,000-5,000 calories per day

Page 31: + MNT in a Residential Eating Disorder Treatment Facility Aly Brown Sodexo Dietetic Internship July 30, 2013.

+Nutrition PrescriptionMacronutrients

Protein: 15-20% total daily caloric intake

Carbohydrate: 50-60%

Fat: 30%

Page 32: + MNT in a Residential Eating Disorder Treatment Facility Aly Brown Sodexo Dietetic Internship July 30, 2013.

+Nutrition PrescriptionWeight & Fluid

2-3 pounds weight gain per week

Fluid: 30-40 mL per kilogram per day Measure fluid intake and output Monitor weights for fluid retention or “water loading”

EN or PN Most severe circumstances

Page 33: + MNT in a Residential Eating Disorder Treatment Facility Aly Brown Sodexo Dietetic Internship July 30, 2013.

+Sample Meal Plans

Meal Plan

Calories Meat/Protein

Milk Fat Starch Fruit Veg Dessert(weekly)

A 1700 5 2 4 6 2 2 3

B 2000 6 3 5 7 2 2 4

C 2200 6 3 6 8 3 2 4

*Fluid: ≥8 cups per day

Page 34: + MNT in a Residential Eating Disorder Treatment Facility Aly Brown Sodexo Dietetic Internship July 30, 2013.

+Other Nutritional Issues Constipation

Avoid bulky foods, increase fiber, and maintain adequate hydration

Low bone density/osteopenia/osteoporosis Calcium: 1,000-1,500 mg per day Vitamin D: 600-1,000 IU Weight gain

Page 35: + MNT in a Residential Eating Disorder Treatment Facility Aly Brown Sodexo Dietetic Internship July 30, 2013.

+General Meal Guidelines

Earn privilege to choose food

Cannot bring anything that could be used to hide food

Prohibited behaviors include: overuse of condiments, using the restroom during meals, using food rituals

Fill out a food diary of their meals along with portion sizes and exchanges Write how they are feeling before or after each meal

Page 36: + MNT in a Residential Eating Disorder Treatment Facility Aly Brown Sodexo Dietetic Internship July 30, 2013.

+Monitoring and Evaluation

Refeeding syndrome Monitor associated labs for appropriate amount of time

Daily or every other day for the first 7-10 days, then biweekly Be aware of symptoms such as altered mental status

Weight/Growth chart trends

Food intake- meet 100% estimated needs

Page 37: + MNT in a Residential Eating Disorder Treatment Facility Aly Brown Sodexo Dietetic Internship July 30, 2013.

+ Presentation of G.V.Anorexia Nervosa

Page 38: + MNT in a Residential Eating Disorder Treatment Facility Aly Brown Sodexo Dietetic Internship July 30, 2013.

+Presentation of G.V.Social history

15-year-old white female

Home-schooled

Lives at home with parents and 6 siblings

Does not feel sense of autonomy

No structure to meals

Poor relationship with father and older sister

Page 39: + MNT in a Residential Eating Disorder Treatment Facility Aly Brown Sodexo Dietetic Internship July 30, 2013.

+ED Onset & Diagnosis

Onset: 11 years old

Started with older sister wanting GV to diet with her GV: “I couldn’t diet as good as her” began restricting and exercising

3 hours a day of exercising + 400-1,000 calories per day

Diagnosis: Anorexia Nervosa (Age 12)

Also diagnosed with Obsessive-Compulsive Disorder

Height: 57.5”

Page 40: + MNT in a Residential Eating Disorder Treatment Facility Aly Brown Sodexo Dietetic Internship July 30, 2013.

+

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+

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+

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+

The Renfrew Center5.29.2013

Page 44: + MNT in a Residential Eating Disorder Treatment Facility Aly Brown Sodexo Dietetic Internship July 30, 2013.

+

Medication/Supplement

Indication

Luvox OCD

Abilify Major Depressive Disorder, Bipolar

Ativan Anxiety

Multivitamin Nutrient deficiencies

Calcium carbonate Osteopenia

Page 45: + MNT in a Residential Eating Disorder Treatment Facility Aly Brown Sodexo Dietetic Internship July 30, 2013.

+Admitting Diagnoses

AN OCD Malnutrition Dental enamel erosion Osteopenia Orthostatic Bradycardic

Page 46: + MNT in a Residential Eating Disorder Treatment Facility Aly Brown Sodexo Dietetic Internship July 30, 2013.

+Day One

Assessment

57.5” 85.5 pounds (90% goal) Goal weight = 95 pounds BMI: 18.2 Lost 6.5 pounds in 6 months Abnormal Labs: Chol 223 H, AST

34 H, ALT 27 H, T4 0.7 L

Page 47: + MNT in a Residential Eating Disorder Treatment Facility Aly Brown Sodexo Dietetic Internship July 30, 2013.

+Day OneDiagnosis

Inadequate energy intake (NI-1.2) related to

anorexia nervosa as evidenced by estimated

energy intake meeting only 25-43% of estimated

calorie needs

Page 48: + MNT in a Residential Eating Disorder Treatment Facility Aly Brown Sodexo Dietetic Internship July 30, 2013.

+Day One

Intervention

Start at “Meal Plan A” – 1,700 calories

Increase to “Meal Plan B” in 5 days – 2,000 calorie

Goals: 48 ounces of Gatorade daily until blood pressure within normal range Complete 100% of meals for six consecutive days Weight gain of 1-2 pounds per week

Page 49: + MNT in a Residential Eating Disorder Treatment Facility Aly Brown Sodexo Dietetic Internship July 30, 2013.

+Day One

Monitoring & Evaluation

Monitor weight, labs, eating patterns, meal intake, and behavioral symptoms

Page 50: + MNT in a Residential Eating Disorder Treatment Facility Aly Brown Sodexo Dietetic Internship July 30, 2013.

+Day Five

Assessment

85.9 pounds (+0.4 pounds since admission)

“Meal Plan B” = 2,000 calories

Restricted food Day Two; 100% meal compliance since

Caught exercising Day Two

Abnormal labs: BUN/Cr ratio 33 H, BUN 21 H

Page 51: + MNT in a Residential Eating Disorder Treatment Facility Aly Brown Sodexo Dietetic Internship July 30, 2013.

+Day FiveDiagnosis

Inadequate energy intake (NI-1.2) related to

anorexia nervosa as evidenced by failure to gain

appropriate weight and restriction of energy-

dense foods from diet

Page 52: + MNT in a Residential Eating Disorder Treatment Facility Aly Brown Sodexo Dietetic Internship July 30, 2013.

+Day five

Intervention

Continue with “Meal Plan B” with addition of supplement – 2,350 calories

Advance to “Meal Plan C” with supplement tomorrow = 2,550 calories

Given warning about exercise

Goals: Weight gain goal increased to 2-4 pounds per week Complete 100% of meals (ongoing) Drink 1.5 cups water with each meal

Page 53: + MNT in a Residential Eating Disorder Treatment Facility Aly Brown Sodexo Dietetic Internship July 30, 2013.

+Day Five

Monitoring & Evaluation

Monitor weight, labs, eating patterns, meal intake, and behavioral symptoms

Page 54: + MNT in a Residential Eating Disorder Treatment Facility Aly Brown Sodexo Dietetic Internship July 30, 2013.

+Day twelveAssessment

85.6 pounds (- 0.3 pounds since last assessment)

“Meal Plan C” plus 2 snacks = 2,800 calories

Family visited this weekend; played tag

100% meal and snack completion

Target weight was increased to 105 pounds

Page 55: + MNT in a Residential Eating Disorder Treatment Facility Aly Brown Sodexo Dietetic Internship July 30, 2013.

+Day twelve

Diagnosis

Inadequate energy intake (NI-1.2) related to

anorexia nervosa and hypermetabolism as

evidenced by failure to gain appropriate weight

Page 56: + MNT in a Residential Eating Disorder Treatment Facility Aly Brown Sodexo Dietetic Internship July 30, 2013.

+Day twelveIntervention

Continue with “Meal Plan C” with two snacks Add one supplement today (3, 150 total calories) Increase supplement to BID tomorrow (3,500 calories)

Goals: Weight gain of 2-4 pounds per week (ongoing) Complete 100% of meals (ongoing)

Page 57: + MNT in a Residential Eating Disorder Treatment Facility Aly Brown Sodexo Dietetic Internship July 30, 2013.

+Day twelve

Monitoring & Evaluation

Monitor weight, labs, eating patterns, meal intake, and behavioral symptoms

Page 58: + MNT in a Residential Eating Disorder Treatment Facility Aly Brown Sodexo Dietetic Internship July 30, 2013.

+Day nineteen

Assessment

89.6 pounds (+ 4 pounds since last assessment)

“Meal Plan C” with 2 snacks and 2 supplements = 3,500 calories

“Meal pass” this weekend

Obtained Mom and Dad’s height Calculated growth potential = 62.5” IBW for 62.5” = 112 pounds

Page 59: + MNT in a Residential Eating Disorder Treatment Facility Aly Brown Sodexo Dietetic Internship July 30, 2013.

+Day nineteen

Diagnosis

Excessive physical activity (NB-2.2) related to

addictive behaviors towards exercise and

increased energy needs as evidenced by

engaging in an hour-long hike

Page 60: + MNT in a Residential Eating Disorder Treatment Facility Aly Brown Sodexo Dietetic Internship July 30, 2013.

+Day nineteen

Intervention

Continue with “Meal Plan C” with two snacks and two supplements Increase supplements to TID = 3,850 total calories

Goals include: “Meal pass” with older sister Complete 100% of meals (ongoing) Weight gain of 2-3 pounds per week

Page 61: + MNT in a Residential Eating Disorder Treatment Facility Aly Brown Sodexo Dietetic Internship July 30, 2013.

+Day nineteen

Monitoring & Evaluation

Monitor weight, labs, eating patterns, meal intake, and behavioral symptoms

Page 62: + MNT in a Residential Eating Disorder Treatment Facility Aly Brown Sodexo Dietetic Internship July 30, 2013.

+Day twenty-one

Treatment Team Meeting

Goals from admission re-visited No longer orthostatic Still with signs of restriction and anxiety

GV caught exercising again Locked bathroom + spontaneous room checks

Weight goal of 112 pounds not agreed upon 105-107 pounds is new target

Page 63: + MNT in a Residential Eating Disorder Treatment Facility Aly Brown Sodexo Dietetic Internship July 30, 2013.

+Day thirty-five

Assessment

Discharged today

96.2 pounds (+ 10.7 pounds since admission)

Goal weight: 105-107 pounds (90-92%)

Height: 57.5”

BMI: 20.4

Page 64: + MNT in a Residential Eating Disorder Treatment Facility Aly Brown Sodexo Dietetic Internship July 30, 2013.

+Day thirty-five

Diagnosis

No nutritional diagnosis at this time

Page 65: + MNT in a Residential Eating Disorder Treatment Facility Aly Brown Sodexo Dietetic Internship July 30, 2013.

+Day thirty-five

Intervention

Nutrition Prescription: 4,100 calories 2 supplements, 2 snacks daily Exchanges: 6 meat/protein, 3 dairy, 6 fats, 8 starches, 3 fruits, 2 vegetables

Goals: Continued weight gain to 105-107 pounds Bone-age study to assess growth potential Weekly outpatient nutrition appointments

Page 66: + MNT in a Residential Eating Disorder Treatment Facility Aly Brown Sodexo Dietetic Internship July 30, 2013.

+Day thirty-five

Monitoring & Evaluation

Weight

Food journals

Vital signs

Labs per protocol

Psychological/Body disturbances

Page 67: + MNT in a Residential Eating Disorder Treatment Facility Aly Brown Sodexo Dietetic Internship July 30, 2013.

+Critical Comments

Stable with acceptable weight for discharge

Goal weight

Bone-age study

DEXA scan

Family therapy

Page 68: + MNT in a Residential Eating Disorder Treatment Facility Aly Brown Sodexo Dietetic Internship July 30, 2013.

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+

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+References

1) Eating disorder NOS (EDNOS): an example of the troublesome “not otherwise specified” (NOS) category in DSM-IV. Fairburn Christopher G., Bohn Kristin. "Editorial Board/Publication Information." Behaviour Research and Therapy 43.6 (2005): 691-701. Web. May 2013

2) "Feeding and Eating Disorders." DSM-5 Development. APA, May 2013. Web.

3) Ries Merikangas Kathleen, Jian-ping He, Burstein Marcy, et al. "Lifetime Prevalence of Mental Disorders in US Adolescents: Results from the National Comorbidity Study-adolescent Supplement (NCS-A)." J Am Acad Child Adolesc Psych (2010): pag. 31 July 2010. Web.

4) Whitney E. N., C. B. Cataldo, S. R. Rolfes. "Eating Disorders." Understanding Normal and Clinical Nutrition. 8th ed. Australia: Wadsworth Thomson Learning, 2002. 270. Print.

5) Escott-Stump Sylvia. "Eating Disorders." Nutrition and Diagnosis-related Care. 7th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2008. Print.

6) Lock J., D. Le Grange, W. S. Agras, A. Moye, S. W. Bryson, and B. Jo. "Randomized Clinical Trial Comparing Family-Based Treatment With Adolescent-Focused Individual Therapy for Adolescents With Anorexia Nervosa." Archives of General Psychiatry 67.10 (2010): 1025-032. Print.

7) Murphy Rebecca, Suzanne Straebler, Zafra Cooper, and Christpher G. Fairburn. "Cognitive Behavioral Therapy for Eating Disorders." Psychiatr Clin North Am 33.3 (2012): 611-27. Print.

8) "National Eating Disorders Association." National Eating Disorders Association. Web. 19 May 2013.

9) Ozier, AD, and BW Henry. "Position of the American Dietetic Association: Nutrition Intervention in the Treatment of Eating Disorders." Academy of Nutrition and Dietetics. J Am Diet Assoc, 2011. Web. 19 May 2013.

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+ 10) Setnick, Jessica. "ADA Pocket Guide to Eating Disorders." Academy of Nutrition and Dietetics. N.p., Aug. 2011. Web. 19 June 2013.

11) Barberio, Judith A. Nurse’s Pocket Drug Guide. 2012. Print.

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17) Barausky, Amy L. "PEDIATRIC NUTIRION –A BUILDING BLOCK FOR LIFE A Publication of the Pediatric Nutrition Practice Group . Update on Eating Disorders and Multi-disciplinary Treatment Teams." Academy of Nutrition and Dietetics. A.I. DuPont Hospital for Children, 2008. Web. 19 June 2013.

18) Morgan, John F., J. Hubert Lacey, and Fiona Reid. "The SCOFF Questionnaire a New Screening Tool for Eating Disorders." West J Med. (n.d.): 164-65. Www.ncbi.nlm.nih.gov. Web. June 2013.

19) Mehler, Philip S., Amy B. Winkelman, Debbie M. Andersen, and Jennifer L. Gaudiani. "Nutritional Rehabilitation: Practical Guidelines for Refeeding the Anorectic Patient." Journal of Nutrition and Metabolism 2010 (2010): 1-8. Print.

20) Lund, Brian C., Elsa R. Hernandez, William R. Yates, Jeff R. Mitchell, Patrick A. McKee, and Craig L. Johnson. "Rate of Inpatient Weight Restoration Predicts Outcome in Anorexia Nervosa." International Journal of Eating Disorders 42.4 (2009): 301-05. Print.

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+22) Butryn, Meghan L., Adrienne Juarascio, and Michael R. Lowe. "The Relation of Weight Suppression and BMI to Bulimic Symptoms." International Journal of Eating Disorders (2010): N/a. Print.

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24) DeSocio, Janeice E. "The Neurobiology of Risk and Pre-Emptive Interventions for Anorexia Nervosa." Journal of Child and Adolescent Psychiatric Nursing 26.1 (n.d.): 16-22. Feb. 2013. Web. June 2013.

25) "What Are Eating Disorders." Alliance for Eating Disorder Awareness. Web. 19 June 2013.

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27) Lock, J Le Grange. "Treatment Manual for Anorexia Nervosa, Second Edition: A Family-Based Approach." (2013): 2. Web. June 2013.

28)Loeb, K., and D. Le Grange. "Family-Based Treatment for Adolescent Eating Disorders: Current Status, New Applications and Future Directions." Int J Child Adolesc Health (n.d.): 243-54. Jan.-Feb. 2009. Web.

30) Warren, Michael. "Endocrine Manifestations of Eating Disorders." The Journal of Clinical Endocrinology & Metabolism 96.2 (n.d.): 333-43. 1 Feb. 2011. Web.

31) Takakazu, Yagi, Ueda Hirotaka, Amitani Haruka, Asakawa Akihiro, Miyawaki Shouichi, and Inui Akio. "The Role of Ghrelin, Salivary Secretions, and Dental Care in Eating Disorders." Nutrients 2.4 (2012): 967-89. Web. June 2013.

32) Arcelus, Jon, Alex J. Mitchell, Jackie Wales, and Søren Nielson. "Mortality Rates in Patients With Anorexia Nervosa and Other Eating Disorders: A Meta-analysis of 36 Studies." JAMA Psychiatry 68.7 (n.d.): n. pag. July 2011. Web. June 2013.

33) "Nutrition Care Process." Evidence Analysis Library. Web. 20 June 2013.

34) Rome, E. S., S. Ammerman, D. S. Rosen, R. J. Keller, J. Lock, K. A. Mammel, J. O'Toole, J. M. Rees, M. J. Sanders, S. M. Sawyer, M. Schneider, E. Sigel, and T. J. Silber. "Children and Adolescents With Eating Disorders: The State of the Art." Pediatrics 111.1 (2003): E98-108. Print.

35) Sim, Leslie A., Donald E. McAlpine, Karen B. Grothe, Susan M. Hines, Richard G. Cockerill, and Matthew M. Clark. "Identification and Treatment of Eating Disorders in the Primary Care Setting." Mayo Clinic Proceedings 85.8 (2010): 746-51. Aug. 2010. Web. June 2013.

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+ 36) Birmingham, C. Laird, and Janet Treasure. Medical Management of Eating Disorders. Cambridge: Cambridge UP, 2010. Print.

37) Naab, Silke, Sandra Shlegl, Alexander Korte, Joerg Heuser, Markus Fumi, Manfred Fichter, Ulrich Kuntz, and Ulrich Vonderholzer. "Effectiveness of a Multimodal Inpatient Treatment for Adolescents with Anorexia Nervosa in Comparison with Adults: An Analysis of a Specialized Inpatient Setting." Eating and Weight Disorders - Studies on Anorexia, Bulimia and Obesity 18.2 (n.d.): 167-73. June 2013. Web. June 2013.

38) Schaffner, Angela D., and Linda Paulk Buchanon. "Evidence-Based Practices in Outpatient Treatment for Eating Disorders." IJBCT 6.1 (n.d.): n. pag. Web. June 2013.

39) Yager, Joel, Michael J. Devlin, Katherine A. Halmi, David B. Herzog, James E. Mitchell, Pauline S. Powers, and Kathryn K. Zerbe. "Practice Guideline for the Treatment of Patients with Eating Disorders." Guideline Watch (n.d.): n. pag. Aug. 2012. Web. June 2013.

41) Mehler, Philip S., Amy B. Winkelman, Debbie M. Andersen, and Jennifer L. Gaudiani. "Nutritional Rehabilitation: Practical Guidelines for Refeeding the Anorectic Patient." Journal of Nutrition and Metabolism 2010 (2010): 1-8. Print.

42) Goodheart, Kristin, James R. Clopton, and Jacalyn J. Robert-McComb. "Chapter 17: Nutritional Evaluation and Treatment of Eating Disorders." Eating Disorders in Women and Children Prevention, Stress Management, and Treatment. Bosa Roca: CRC, 2011. N. pag. Print.

43) Reel, Justine J. "Dialectical Behavior Therapy." Eating Disorders: An Encyclopedia of Causes, Treatment, and Prevention. Santa Barbara, Calif: Greenwood, 2013. N. pag. Print.

44) Katzman, Debra K., and Madhusmita Misra. "Bone Health in Adolescent Females with Anorexia Nervosa: What Is a Clinician to Do?" International Journal of Eating Disorders (n.d.): n. pag. 9 May 2013. Web. June 2013.

45) Mehler, Philip S., and Arnold E. Andersen. Eating Disorders: A Guide to Medical Care and Complications. 2nd ed. Baltimore: Johns Hopkins UP, 2010. Print.

46) The Renfrew Center. Nutrition Handbook and Standards of Care.

47) "Pediatric Nutrition Care Manual." Behavioral Health – Eating Disorders (n.d.): n. pag. American Dietetic Association, 2012. Web. June 2013.

48) ADA Pocket Guide to Nutrition Assessment. Second Edition. P Charney, A Malone. 2009.

49) Le Grange, Daniel, Peter M. Doyle, Sonja A. Swanson, Kali Ludwig, Catherine Glunz, and Richard E. Kreipe. "Calculation of Expected Body Weight in Adolescents With Eating Disorders." Official Journal of the American Academy of Pediatrics 129.2 (n.d.): n. pag. Pediatrics, 4 Jan. 2012. Web. June 2013.

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+15 year old FemaleHeight: 62.5”

IBW: 104 lbs

IBW: 112 lbs

McLaren Method

Moore Method


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