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August 18, 2019

If we don’t avoid refeeding syndrome all these these fluid and electrolyte shifts can result in cardiac abnormalities, arrhythmias, heart failure, cardiac arrest, seizures weakness Hi guys! My name is Bari I am registered dietitian nutritionist and I’m taking over Kim’s Youtube channel today to discuss the medical nutrition therapy for Anorexia Nervosa specifically in the inpatient setting. Eating disorders, specifically anorexia is um a mental health disorder so we approach these a bit differently, super sensitive and you know everyone is different they require different care and that’s why I’m going to be talking about the inpatient side because it is a bit more standard um than the outpatient What is Anorexia Nervosa (AN)? and this definition is based off of the ICD-10 codes So AN is persistent restriction that results in low body weight and low body weight is defined as 15% below what is expected for age, height weight, gender or BMI less than 17.5 and there are 2 subtypes to AN so either the restrictive subtype or the binge purge subtype. We see body image distortion and an intense fear of weight gain. There used to be a criteria for amenorrhea which is the lack of a menstrual cycle but according to the new DSM-5 codes that has been eliminated. Why is the dietetic role so important in the treatment for patients with AN? So we are kind of the first line of treatment when it comes to the inpatient setting so for example when someone comes in they’re malnourished but there brain is also malnourished so there cognitive abilities are not at the maximum efficiency so things like… before the doctor will even start to prescribe medication or before the psychiatrist begins therapy, they do wait until the patient is refed and the brain is back to a nourished state so we are a very important part of the MDT or the multi- disciplinary team next would be following the nutrition care process and and I’m going to skip all the way to intervention because the first 2 steps of assessment and diagnosis can take a whole nother YouTube video so I’m just going to skip to intervention. So our 2 main goals for intervention would be weight restoration and avoid refeeding syndrome so I’m going to focus on refeeding syndrome a bit for now Refeeding syndrome is a shift of fluids and electrolytes that may occur when previously malnourished or starved patients begin to be fed again so what happens was prior to admission the patient was in a state of ketosis due to a lack of nutrition and then when they’re admitted and we start to feed them again it switches to carbohydrate metabolism and this switch can cause rapid metabolic changes changes in electrolytes like phosphate, sodium, potassium, magnesium and these are all intermediates of you know glucose breakdown so think of glycolysis and the Krebs cycle and when we switch they’re being used so quickly and other things like cofactors like thiamine so if we have a rapid depletion of thiamine we can have a deficiency resulting in Wernicke’s encephalopathy or cardiomyopathy we can also have a build up of lactate in the blood um.. cause it can enter the Krebs cycle and this can turn into lactic acidosis which is dangerous for the patient as well. So if we don’t avoid refeeding syndrome all the fluid and electrolytes shifts can result in cardiac abnormalities arrhythmias heart failure, cardiac arrests seizures, …weakness, edema, etc the list goes on and it does put your patient at a high risk for survival so we want to avoid that so how do we do that? so we really want to make sure we’re identifying those at high risk for refeeding syndrome and what makes someone at high risk would be minimal or no intake um for 15 days prior to admission so this is something that you would ascertain in the assessment portion of the nutrition care process and also things like low electrolytes before being fed again biochemical data that you would obtain during the assessment things like looking at the sodium, potassium, phosphate levels and if they’re low prior to being fed you know making sure you talk to the doctor and ordering a prophylactic multivitamin. and then also any patients with any BMI less than 16 will be at high risk as well. How do we feed these patients with avoiding refeeding syndrome? and it’s definitely a challenge and the 1st thing that we should always do is make sure we know what they were having prior to admission because we never want to feed them less than they we already getting. so we normally start low. We start at about 20 kcal/kg or even less if we need to and we’re always the monitoring electrolytes. and this is the great part of monitoring and evaluation because it is a continual process and we adjust as we go along. and we always the diet to be low in simple sugar because that will help the breakdown or the switch to a carbohydrate metabolism is quick already and that will just speed it up. and then want a diet that is low in fiber because patients with AN already suffer from delayed gastric emptying and the fiber will slow that down even more. but we also engage in nutrition counseling and education that is a whole nother YouTube video as well so just focusing on the refeeding. we have to keep in mind that patients are often in a hyper metabolic phase during weight restoration and even up to 1 year after weight restoration and what this means is that there metabolisms are on overdrive and so when we plug our data into equations like the Harris Benedict or the Mifflen St. Joer we might get a certain number but we have to understand that it’s going to be higher and we have to adjust accordingly. so someones metabolic rate might come out as 1500 to maintain weight and we actually need to feed them 3000 to 4000 calories to weight gain because their metabolism is working so hard to keep them alive so that is important to keep in mind as well so we do start slow and we build up to that and we do have a food 1st approach so do want our patients to be eating their food on their food trays if they cannot reach their goals or cannot eat enough we do offer things like Ensure, Ensure Plus we want things with high calorie low volume which will avoid the fluid shifts and if they refuse to eat the doctor may order a tube feed may order a tube feed which is absolutely fine and we always want to feed them again a formula that is high calorie, low volume to avoid the refeeding syndrome and we want to feed them on a bolus feed so this will mimic meal times so when we d o phase them into solid foods, Our main goals were weight gain ideally you know 1-2 lbs a week in the beginning phase and then that can increase once they pass; once we know they’re not going to suffer from refeeding syndrome and the other is to maintain the electrolyte levels within normal limits so avoiding refeeding syndrome so that is basically the MNT related to inpatient AN specifically how to feed the patient so if you have any Q cause I might have mentioned a few tricky terms pop them into the comments section I will get back to you Remember to follow me on my social media platforms so my handle is: and also don’t forget to subscribe to Kim’s YouTube channel and share this video. Thanks for watching.

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  1. Hi Kim! My name is Emma Koons, and I am a freshman at Florida State University majoring in dietetics. I am creating a research paper in my english class, in which I must interview 3 dietitians. Would you be available to
    conduct this interview over e-mail? I completely understand if not, I just thought it would be very interesting to hear from someone who is in the public eye like you. Thank you for all that you do!

  2. Thank you so much for posting this! I really want to work with eating disorder patients but my classes barely touch on the subject and I'm not sure where to find more information on nutrition counseling for these patients. Most information tends to fall on the psychological side of counceling

  3. How do you figure out target wt for patients if they arrive already at 100% IBW (i.e. 5ft and 100 lbs pt). They clearly have a hx of eating disorders and were dx with AN. But how do you know if they're current weight should be higher (or how much higher)?

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