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Mary Fraser

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Case Study #2
Monday 6/25/18

Patient Background Information:

Macy is a 19 y/o female presenting with daily binge-eating behaviors. Macy reports a history of
restriction and binge-eating behaviors since age twelve, and a recent escalation in daily binge-eating
behaviors in absence of restriction. Macy has Poly-Cystic Ovarian Syndrome (PCOS) and a diagnosis of
Borderline Personality Disorder. Her recent lab work reflected a HGA1C of 5.7%, fasting blood glucose:
114; while all other values were WNL. EKG, Dexa Scan, and vitals were also all WNL. Her height was
measured at 5’5” and her weight was measured at 285#. Client is currently not on any medications and
stopped seeing her previous psychiatrist and therapist (where she received dx of BPD) at age 15.

Macy reports that she regularly sleeps until ~ 3:00 pm, eats first at 5:00 pm, then binges from 9:00
pm – 12:00 am. Macy reports her binges including foods from diners ordered over seamless, and the types
of food changing daily. Based on 24 hour food recall, client is ingesting ~ 7,000 kcal/day including binges.

Macy reports observing her mother binge-eating and father restricting and following commercial
diet programs during formative years.

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Case Study Report:

Macy is a 19-year-old woman presenting with daily binge behaviors and a history

of restrictive eating and purging since age 12. Macy’s past involves observing her mother

binge eating and father restricting and following commercial diet programs during her

formative years. Macy meets the DSM -5 diagnosis for Binge Eating Disorder, with an

emphasis on night eating, as she regularly both eats a large amount of food within a

discrete period of time and has a sense of lack of control during the eating/ binge episode.

Additionally, Macy currently has an unusual sleep pattern, by sleeping regularly until

3pm in the afternoon, which delays her first meal until around 5pm. Macy’s binging then

starts around 9pm and continues until midnight, and this binging behavior escalates when

she does not restrict. If this is once a day, her binging is considered moderate, but if it is

between 7-13x a week, it is considered severe.

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Macy appears to currently be regularly consuming excessive calories during her

binging episodes as indicated by her 24-hour recall, which indicated a consumption of

over 7000 calories a day. In addition, Macy has polycystic ovarian syndrome and was

diagnosed with borderline personality disorder 4 years ago at age 15. Macy is currently

not taking any medications for these conditions or any other and has stopped seeing her

psychiatrist and therapist.

Macy’s current lab work reflects a HGA1C of 5.7%, and fasting blood glucose of

114, indicating prediabetes, while other labs and her EKG were in normal range. At 5’5”

285 lbs, and 19 years old, Macy has a BMI of (lbs/in ) x 703 => (285/65 ) x 703 => 47.4
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BMI. As Macy is > 40 BMI, she is considered extremely obese class III. (Krause p.390)

Macy’s IBW calculates to be: 100 + (5x5) => 125 lbs. As a percentage of IBM, 285 x

100/125 => Macy is at 228% IBW.

Since Macy is at 228% IBW, we should use adjusted BW x 1.3-1.5 to calculate

her REE. Adjusted BW for women = [(Actual BW - IBW) x 0.32] + IBW => [(285-125)

x. 0.32] +125 => 176 lbs or 79.8 kg adjusted BW. REE is calculated as (10 x kg) +

(6.25 x cm) - (5 x yrs) -161 => (10 x 79.8kg) + (6.25 x 165cm) – (5 x 19) -161 => (798

+ 1031)- 95 -161 => 1573 REE x1.3 to 1.5 => REE range of (1573 x 1.3) = 2045 &

(1573 x1.5)= 2360. So, Macy’s daily caloric range should be approximately 2100-2300

calories/day based on her adjusted weight.

The level of care chosen for Macy will have to be monitored. Since she is

currently at an ‘extremely obese’ weight level, has borderline personality disorder, binges

nightly, is prediabetic, does not exhibit the responsibility of regularly visiting her

psychiatrist or therapist, and does not eat or sleep on a normal schedule, her conditions

and mood need to be watched. Depending on the severity of her BPD, emotional status,

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and ability to get her binging and sleeping under control, Macy’s level of care treatment

will need to be increased or decreased.

The recommended appropriate level of care for Macy to start treatment could be

level 3 full day outpatient, as long as she is medically and psychiatrically stable and

motivated enough to be able to decrease her binging, start to normalize her eating and

sleep patterns, return to a psychiatrist, and make it to the scheduled meetings and

facilities. As she is so obese at the young age of 19 and has had a history of ED since age

12, Macy’s ED condition has been going on for most of her mature life without resolution

and so more care than used in the past is recommended. A long-term approach is

recommended which would incorporate physical, behavioral and psychological treatment.

Macy’s irregular sleep pattern may make it hard to get to the treatment facility and make

scheduled appointments. Additionally, as her binging is occurring at night, an outpatient

setting may not work for her, but can be tried as a first option. Her excessive weight may

make it hard for her to exercise or move well and limiting exercise until her labs are more

stable is advised.

Macy should be examined by a medical doctor to make sure that she has not

developed other medical conditions and is medically stable. She should also see a

psychiatrist for medication and re-evaluation for BPD, consult regularly with a therapist

to work through her emotional and mental concerns and fears, as well as work with a

nutritionist to help her get stabilize her weight and develop better eating habits. It is

important to get her started with the therapist and psychiatrist to work with her on her

borderline personality disorder diagnosis and other emotional issues. The therapist can

help Macy reframe her beliefs about appearance, body image and issues with her parents

and others regarding her appearance and weight. A sleep specialist may also help Macy

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determine why she is having trouble with her sleep pattern. Macy would also work with a

nutritionist to address beliefs regarding what types of foods she should be eating,

amounts and health, along with ways to eliminate the body’s physiological urge to binge

by better spreading caloric intake throughout the day. This should also help stabilize her

blood glucose levels. The entire therapeutic team should be on the watch for the client

‘splitting’. Some therapies that can help Macy with her beliefs about food, habits with

sleep, and physiological urges to eat, include Cognitive Behavioral Therapy,

interpersonal therapy, sleep training, relaxation therapy, and modeling food exposures.

If she is not medically stable, does not have her conditions improve or if new medical

issues are uncovered, Macy would need to up her level of care.

A meal plan would need to be discussed and chosen by the client to encourage

better compliance. The goal would be to create and incorporate the RO3 daily meal plan

(3 balanced meals and 3 snacks) into the patient’s life. We would start by adding in the

lowest risk binge foods, 1 at a time, to better distribute calories throughout the day,

working backwards from when she wakes up, starting with a snack, until eventually a full

day is normalized with 3 meals and 3 snacks. It is important to get her to normalize her

sleeping and waking patterns in order to control her eating patterns. Check-ins should

progress from daily, to a few times a week, to monthly, to every few months, for several

years. The goal in treatment with BED is to be consuming a variety of 3 real meals and 3

snacks from different cuisines, in normal portions balanced throughout the day with food

neutrality. The end goal would be to eat more mindfully, prevent further weight gain,

gain body acceptance, and improve her physical health. BED recovery can take between

7-14 years, and Macy would be advised to keep check-ins with a nutritionist and therapist

over this time period.

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Compliance with a meal plan is determined by results and observation. First, the

patient would stabilize sleep and eating patterns and stop gaining weight. We also would

like to see her fasting blood glucose get under 100 and would aim to have her symptoms

of PCOS reduce. Calorie intake may need to be modified and adjusted for her as

recovery progresses if her weight changes. Slight weight changes up or down should be

monitored for 1-2 weeks before a conclusion is drawn about direction and success. The

main goal here is to stabilize the client and make sure she stops gaining and starts living a

healthier lifestyle. This include cessation of binging, improvement of self -esteem, and

body acceptance. A safe weight goal (BAW) should be established for reference for the

patient to maintain good health and mental function. (Herrin & Larkin)

By Mary Fraser, Nutrition & Dietetics, NYU. June 25, 2018.

References:

Herrin, M & Larkin, M. Nutrition Counseling in the Treatment of Eating Disorders, Second Edition.
Routledge. New York. 2013.
Mahan LK, Raymond JL. Krause’s Food & The Nutrition Care Process, 14th Ed. Elsevier Inc, St. Louis,
MO. 2017.
Setnick, Jessica. MS, RD, CEDRD. The Eating Disorders Clinical Pocket Guide, Quick Reference for
Healthcare Providers, Second Edition. 2013.