Eating disorders are serious mental illnesses that can be life-threatening. Especially anorexia nervosa (AN) has a high mortality rate compared to other psychiatric diseases (AEDReport 2012). For prepubertal individuals, it is important that the expected weight gain is not achieved during the growth period. If the ideal body weight is less than 75%, hospitalization is required (ADA 2006).
The ideal standard of care; It includes early diagnosis and timely intervention, evidence-based treatment and multidisciplinary team approach (medical, psychological, nutritional) (AEDReport 2012). Medical nutrition therapy plays an important role in the treatment of AN and the prevention of its complications. Medical nutrition therapy; It is applied individually according to the patient's physical and laboratory findings and the medical treatment he receives. First, the individual's nutritional status and knowledge, motivation, current eating habits, behavioral status and laboratory findings are evaluated (ADA 2006). Laboratory and imaging practices recommended in the initial evaluation of a patient with an eating disorder and the anomalies corresponding to these practices are summarized in Table 1 (AEDReport 2012). A nutritional treatment plan is then developed in collaboration with the treatment team. If possible, the dietitian establishes a trusting relationship with the patient and maintains constant contact with the patient throughout the course of treatment (ADA 2006). Treatment programs generally include; It includes the stages of weight loss prevention and stabilization, weight gain and weight maintenance (Schebendach 2012).
Basic elements in nutritional treatment; nutrition education, meal planning, establishing regular eating habits and preventing the patient from dieting (ADA 2006). Individuals generally know the energy values of foods very well; They prefer fiber foods with low carbohydrate and fat content (such as salads and boiled vegetables). They consume almost no floury foods such as bread, rice and pasta. In a study, the eating behaviors of individuals with AN before and after treatment (after Body Mass Index (BMI): weight (kg)/height (m)2) was ≥19.5 kg/m²) were examined, and post-treatment calorie and fat consumption rates were examined. It was found to be significantly increased compared to before treatment. On the other hand, both situations The amount of calories and fat consumed was found to be significantly lower compared to normal individuals. (Mayer et al. 2012).
These patients generally prefer liquid foods rather than solid foods (Bozbora 2008). They mostly consume high amounts of caffeine through coffee, tea and low-energy sodas. When these drinks are limited, caffeine withdrawal symptoms may occur (Royal College of Psychiatrists 2005). Some patients seriously restrict fluid intake due to a feeling of bloating. For this reason, it may be necessary to monitor urine specific gravity and serum electrolytes (Schebendach 2012).
Vegetarianism is much more common in AN than in the general population. A detailed anamnesis of the individual's social, cultural and religious practices should be taken to evaluate whether the development of vegetarianism is due to AN. In treatment, the individual's beliefs should be respected. Multivitamin and multimineral supplements should be given when necessary. It is very difficult to provide sufficient phosphate to prevent hypophosphatemia at the beginning of treatment, especially in vegans (due to non-consumption of dairy products), and phosphate supplements may be required (Royal College of Psychiatrists 2005).
Weight gain is very important in the treatment of AN. . Without weight gain, patients can face serious, even fatal medical complications. However, the nutritional therapy process can also be risky for patients. Giving high calories to patients with severe malnutrition in the early period may cause medical problems and even create life-threatening clinical pathologies.
In the guidelines of the American Academy of Pediatrics, inpatient treatment It is emphasized that nutrition can be provided via nasogastric tube or intravenous route when necessary for AN patient (Bulik et al. 2012).
Nutritional treatment goals for AN; It is associated with normalizing eating patterns and achieving a healthy weight (ADA 2006). In the American Psychiatric Association guidelines, it is emphasized that the target weight should be determined and controlled weight gain should be ensured to reach this target (For example, in patients receiving inpatient treatment, approximately 0 weight should be achieved). .5-1 kg/week, for patients receiving outpatient treatment, approximately 0.25-0.5 kg/week, the target can be set between these two values for patients receiving intensive outpatient treatment or partially hospitalized patients) (Bulik et al. 2012).
In general, the nutritional needs and goals of anorectic individuals are aimed at reaching the ideal body weight. Body weights of patients can be evaluated according to BMI. Standard tables regarding ideal body weight may not be appropriate for use in adolescents (Mehler et al. 2010). For adolescents, it may be more appropriate to use the height and weight tables in Neyzi et al.'s (2008) publication titled "Body weight, height, head circumference and body mass index reference values in Turkish children". Figure 1 shows BMI percentile curves for boys and girls aged 2-18; Those below the 5th percentile are considered "underweight", those between the 5th and 85th percentiles are considered "normal", those between the 85th and 95th percentiles are considered "overweight", and those above the 95th percentile are considered "obese".
Regardless of the re-feeding method, weight gain of 10% of the ideal body weight is an acceptable value. There are also opinions that the weight at which normal menstruation has occurred in the past is a "healthy weight". However, if amonorexia continues, the ideal body weight must be reached, and this value may even be slightly exceeded (Mehler et al. 2010).
Calorie intake is initially 30-40 kcal/kg. /day (can also be started as 1000-1200 kcal/day) and should be increased gradually (ADA 2006). It is generally recommended to increase total energy by 100-200 calories every 2-3 days. The recommended calorie intake at the end of treatment is 70-100 kcal/kg/day (3000-4000 kcal/day for women, 4000-4500 kcal/day for men). Since the amount of energy spent by many AN patients is high, the energy spent due to physical activity should be taken into account. After the target weight is reached, the caloric value can be reduced slightly to maintain the weight, but due to the continuing potential growth and development in adolescents, excessive restrictions should not be made and the caloric value should be kept high.
The fat rate of the diet, the total intake calories approximately It should be around 30% and the protein content should be 15-20%. The minimum amount of protein needed is equal to the RDA (Recommended Dietary Allowances) value calculated based on ideal weight, gender and age. The amount of carbohydrates should constitute 50-55% of the calories taken. Insoluble fiber sources are recommended for constipation complaints, which are common in these patients.
Vitamin and mineral supplements are not used routinely, but increasing needs with weight gain should still be taken into consideration. Vitamin that meets all RDA values and mineral supplements can be applied, but iron supplementation may be contraindicated at the beginning of treatment. During treatment, 25 mg/day thiamine can be added and the dose can be increased if thiamine deficiency is detected. There is no clear consensus regarding calcium and vitamin D supplementation in this patient group; Consumption of foods rich in calcium and vitamin D should be encouraged due to the risk of low bone mineral density.
Delayed gastric emptying is common in patients with AN, along with complaints of abdominal distension and discomfort after eating. Food intake is generally low at the beginning of treatment and three meals a day can be tolerated. However, as the amount of energy consumed increases, nutrition between meals also becomes important (Schebendach 2012).
Long-term training for behavioral change is important. The patient should be made aware of the appropriate weight for his/her height and the effects of foods on health (Baysal 2002).
Nutritional status >) evaluation and treatment
Anorexia nervosa can result in serious deficiencies in all types of macro and micronutrients, and this can sometimes be life-threatening. Daily food intake, weight loss in recent months and affecting factors, vomiting habits, gastrointestinal system functions, hydration, restrictions, co-morbidities and alcohol intake should be questioned in detail. After a detailed physical examination, anthropometric measurements (weight, body mass index, triceps skin thickness, etc.) as well as some laboratory tests are used to determine the nutritional status of the patients. laboratory tests are used. Complete blood count, serum electrolytes, proteins, iron and iron binding capacity, ferritin, vitamin B12, folate and 25-OH vitamin D levels should be examined. Nutritional screening and evaluation tests can be used in follow-ups after weight gain following treatment. Nutritional Risk Screening (NRS-2002) 2002 (Kondrup 2003) (Table 2) or Subjective Global Assessment Test (Detsky 1987, American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) Board of Directors and Clinical Practice Committee2010) (Table 3) can be used for this purpose.
AN causes severe malnutrition and as a result, fluid losses occur in body compartments (intracellular/extracellular), intracellular and Extracellular electrolyte imbalance develops (especially sodium, potassium, magnesium and phosphorus), sarcopenia occurs. A tendency to infections (immune deprivation) develops, and sudden death (arrhythmia, acute renal failure, shock, etc.) may occur. Complications may occur due to rapid replacement therapy (LondonRoyal College of Psychiatrists Council Report CR130, 2005).
Anemia may be seen in the complete blood count. There is often iron deficiency. Other causes include vitamin B12 and folate deficiency. When deficiencies are detected as a result of laboratory analysis, slow replacement should be made. Apart from this, anemia may also occur as a result of hemodilution after fluid replacement.
One of the most important problems is serum electrolyte imbalance. The incidence of hypokalemia increases due to excessive vomiting, laxative use and nutritional disorders (Connan 2000). For similar reasons, hyponatremia, hypomagnesemia and hypophosphatemia are also common. Especially during treatment, the presence of serum electrolyte imbalance can result in mortality. Deficiencies should be investigated at regular intervals and corrected by replacing them. Hyponatremia may occur as a result of deficiency and loss, or it may develop with excessive hydration after fluid replacement therapy. In such cases, improvement will be achieved with fluid restriction (Santonastaso 1998).
Since serious weight loss will cause a slowdown in metabolic rate after a while, the resting energy needs of these patients decrease over time. this ned
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