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Can We Eat Dessert? Managing Binge Eating Disorder and Co-‐occurring Type 2 Diabetes By Meg Salvia, MS, RDN, CDE Walden Behavioral Care & Meg Salvia Nutri;on
Objectives
• Summary of diagnosis and management of diabetes
• Summary of diagnosis and management of binge ea;ng disorder
• Prevalence & significance of co-‐occurring diseases
• Nutri;on management of diabetes, then binge ea;ng disorder
• Synthesized nutri;on management of co-‐occurring diagnoses
• Case Studies
• Ques;ons & Discussion
Type 2 Diabetes (T2DM) • Hallmarks of T2DM: Progressive disease course • Insulin resistance • Decreased beta cell func;on
Normal Prediabetes Diabetes
Fas1ng BG (mg/dL)
< 100 100-‐125 126
A1c (%) 4.0-‐5.6 5.7-‐6.4 6.5
Body releases insulin
Insulin resistance
Hyperinsuilnemia (increased excre;on)
Rela;ve insufficiency
Decreased beta cell func;on/produc;on
Exogenous insulin
Hyperglycemia
Binge Eating Disorder (BED) • Diagnos;c criteria recently added to DSM-‐5 • Recurrent episodes of binge ea;ng • Episode is characterized by:
• Ea;ng an amount of food that is definitely larger than what most people would eat under similar circumstances within a discrete period of ;me A sense of lack of control over ea;ng during the episode
• Associated with 3 or more of the following: • Ea;ng more rapidly than normal • Ea;ng un;l feeling uncomfortably full • Ea;ng large quan;;es when not hungry • Ea;ng alone due to embarrassment • Feeling disgusted with oneself, depressed, or guilty
• Marked distress • Occurs at least 1x per week for 3 months • Not associated with compensatory behaviors
Prevalence
Type 2 Diabetes 29 million 9% of popula;on (6% in Vermont)
37% of adults have prediabetes
Binge Ea;ng Disorder 9 million
2.8%
Diagnosis is rela;vely new, Treatment underu;lized
Both Dx (es;mated)
~3.5 million 12% of T2DM
Impact and Interaction • BED is most common ED dx in T2DM pa;ent popula;on • Does binge ea1ng contribute to development of T2DM? • Binge ea;ng episodes can contribute to weight, obesity status • “Independent of BMI, female binge eaters are more likely to develop DM.”
• Does T2DM dx lead to binge ea1ng behaviors? • Pa;ents with DM at increased risk for ED
• Depression & die;ng history may play a role
• Does BED lead to worse T2DM outcomes? • ED in T2DM associated with worse metabolic & psychological outcomes
• ED + DM associated with increased risk of complica;ons
• Binges can consist of large CHO quan;;es • Some research finds no difference in A1c with BED dx
Through the Lens of the Patient: Life With DM • Psychosocial considera;ons • Depression, guilt, and shame
• Fear of complica;ons
• Tools for managing BG • BG checking
• Frequency • Not everyone with T2DM self monitors BG
• Lifestyle modifica;ons • Nutri;on (details to come)
• Physical ac;vity • 150 minutes/week
• Recommenda;ons for weight loss • Impact greatest early in disease progress
• Research supports weight loss prevents progression of preDM to T2DM
MNT Physical Ac;vity
Lifestyle Modifica;ons
Diabetes Medications
Mekormin Combina;on Therapy
Insulin
• Medica;ons that increase risk of hypoglycemia: • Sulfonylureas • Megli;nides • Insulin • Not Mekormin
• Insulin requires alen;on to CHO intake: • Fixed daily doses: consistent CHO amount & ;ming • Intensive insulin therapy (similar to T1DM)
Diabetes 911 What ED Providers Need to Know • What are the medical crises that can happen in T2DM? • Hyperglycemia Treat with medica;on or hospitaliza;on
• Diabe;c ketoacidosis (DKA) • Hyperosmolar Hyperglycemic Syndrome (HHS/HHNS)
• Hypoglycemia Treat with CHO • Recall that insulin or sulfonylureas increase risk
Hyperglycemia Symptoms Hypoglycemia Symptoms
Frequent thirst Shakiness
Frequent urina;on Swea;ng or clamminess
Headaches Pounding heart, anxiety
Tiredness, fa;gue Irritability, impa;ence
Blurry vision Weakness, fa;gue
Difficulty concentra;ng Confusion
Nutrition for Diabetes: The Basics • Goals (from the ADA) • Improve glycemic control
• Reduce CVD risk • Achieve & maintain body weight goals
• Delay or prevent complica;ons
• Maintain pleasure of ea;ng • Provide prac;cal tools for day-‐to-‐day management
• Op;mal mix of macronutrients: Doesn’t exist • Amount of CHO is the most important factor in BG impact
• Quality of fat is key • Protein + CHO increases insulin response
Nutrition for Diabetes: Carbohydrates • Carbohydrate coun;ng • Why 60 grams of carbohydrate at a meal?
• Dietary Guidelines (2010): 50-‐65% of daily kcal from CHO
• 2000 kcal diet = 250-‐300 g CHO per day 60 g per meal and 15-‐30 g per snack
• What if 2000 kcal per day is an inappropriate goal?
• Low Carb = less than 45% of kcals from CHO • ADA Diet
• Moving away from one-‐size-‐fits-‐all ea;ng palerns
• Glycemic Index • Glycemic load
• Fiber
Nutrition for Diabetes: First Steps for ED Providers • Get a clear understanding of the DM treatment plan • Diagnosis (prediabetes versus diabetes) • Labs: A1c, fas;ng BG, BG palerns • Medica;on plan & BG monitoring
• Ask: Does your DM provider know about BED dx or binge behaviors?
• First few weeks: will BED treatment influence DM treatment? • Assess understanding of DM nutri;on recommenda;ons
• What is a CHO? What does 15 g of CHO look like?
• Exchange-‐based systems: 1 grain = 15-‐20 g CHO
• Changes in P.O. intake can some;mes result in needed medica;on changes collaborate & communicate
• Understand nutri;on and weight messages pt may have heard from DM perspec;ve
Through the Lens of the Patient: Life With BED • Psychosocial Considera;ons • Guilt & shame (sound familiar?)
• Die;ng history • Rigidity or Black-‐and-‐White Thinking
• Tools for Managing BED • Interdisciplinary team
• Therapist/clinician • Medica;on management (MD or NP)
• Successful psychological models: CBT, DBT
• Goals: • Interrupt, reduce binge behaviors • Meet nutri;on needs and support short-‐ and long-‐term health
• Heal rela;onship with food • Build addi;onal coping skills in place of food
Nutrition & BED: The Basics • Meal plans & meal palerns • Provide nutri;onally adequate plan ini;al goal is not weight loss but binge symptom reduc;on
• Meal plan con;nuum: • From structure & support to intui;ve ea;ng
• Assess frequency, quan;ty, and content of binges • If you can… lots of secrecy here
• Key Concept: Neutrality • Permission means no food is off limits
• Challenge foods & dessert included
Hunger
Denial
Binge
Shame & Resolve
5 Key Principles for BED • Adequacy
• Ea;ng at least 3 meals per day
• Snacks between meals
• Balance • All food groups included in meals
• Variety • Try different foods within each food group • Mix up setng, prepara;on, and environment
• Modera;on • The other side of the coin of adequacy • Por;on sizes
• Nourishment • Food feeds our bodies & souls • There are other reasons to eat apart from hunger • Not the “hunger & fullness” or “mindful ea;ng” diet
Intuitive Eating
• Reject the diet mentality
• Learn about hunger & fullness
• Enjoyment & sa;sfac;on
• Cope with emo;ons without using food
• Respect your body and health
• Depression & psychological impact is huge • Connect to mental health support is essen;al for ED pa;ents
• Iden;fy binge behaviors you might be the first to know! • Ques;ons to ask:
• Is your ea;ng different when you’re alone versus with others? • Does your ea;ng ever feel out of control, or like you couldn’t stop if you
wanted to? • Palerns to look for:
• Skipping breakfast, lunch, PO intake earlier in the day to compensate • Elevated BG (especially in the morning) without explana;on • Missing BG checks when dosing insulin • Inexplicable weight palerns (rapid/linear gain, not matching PO intake,
episodes of significant/day;me restric;on) • Inability or reluctance to log food or BG • “I know what to do, I just need to do it.”
• DM Nutri;on counseling for binge behaviors • Diffuse charged language and black-‐and-‐white thinking • Bringing food decisions into a neutral place
BED 911 What DM Providers Need to Know
BED + DM: Synthesized Plan • Goals:
• Meet nutri;on needs without exacerba;ng behaviors
• Improve glycemic control for short-‐ and long-‐term health
• Clarify and support adherence to DM plan
• Reduce frequency & quan;ty of binge behaviors
• Help pa;ents manage emo;on & psychological distress
• Provide ongoing support and educa;on
BED + DM: Synthesized Plan • Basics: First to reduce binge behaviors (days to weeks) • Inclusion of carbohydrates
• Por;on sizes & exchanges • Assess degree to which CHO coun;ng is appropriate
• Balancing carbs with protein & fat • Regular meals and snacks • Help manage ;ming and hunger • Establish BG monitoring plan
• Intermediate goals: (weeks to months) • Prac;ce health-‐suppor;ng behaviors • Foster curiosity (BG monitoring around individual choices… details next)
• Advanced topic: Heal rela;onship with food (months +) • Awareness of hunger and sa;ety cues • Permission around food and neutrality • Build trust
Desserts & Challenge Foods • Keys: Trust & Curiosity
• Tools for building TRUST through nutri;on counseling: • Structured introduc;on • Challenge meals with you • Stair-‐step planning tool • Hunger scale • “Seven hungers”
• Curiosity: Specific BG palerns • BG “check” versus “test”
Weight: Circling Back to an Important Topic • Recall: • Weight loss is a recommenda;on for prediabetes, early T2DM • Weight loss is not a goal of BED tx programs, intui;ve ea;ng
• So, if weight loss is a goal, which diet should we recommend? • Research doesn’t support any par;cular diet for weight loss • Die;ng owen results in increased weight
• Research on mindful ea;ng or intui;ve ea;ng on glycemic control & weight goals is emerging and intriguing
• Reframe: • Interrupt palern of ongoing weight gain • Reduce frequency and quan;ty of binges • Improve glycemic control (reduce risk of complica;ons) • Weight loss may occur – clinically significant wt loss doesn’t need to be large
Weight: Impact of Reducing Binge Behaviors
IBW range
Binge behaviors
Elevated weight
Case Studies
Resources: Diabetes Avert, et al. Nutri1on therapy recommenda1ons for the management of adults with diabetes.
Diabetes Care 2013.
References • Evert AB, Boucher JL, et al. “Nutri;on Therapy Recommenda;ons for the Management of
Adults with Diabetes.” Diabetes Care, 2013. • Franz MJ, Boucher JL, et al. “Evidence-‐Based Diabetes Nutri;on Therapy Recommenda;ons
Are Effec;ve: the Key is Individualiza;on.” Diabetes, Metabolic Syndrome, and Obesity, 2014.
• Jakubowicz D, Wainstein J, et al. “Fas;ng Un;l Noon Triggers Increased Postprandial Hyperglycemia and Impaired Insulin Response awer Lunch and Dinner in Individuals with Type 2 Diabetes: A Randomized Clinical Trial,” Diabetes Care, 2015.
• ADA Standards of Medical Care in Diabetes, Diabetes Care Supplement, 2016 • Miller CK, Kristeller JL, et al. “Compara;ve Effec;veness of Mindful Ea;ng Interven;on to a
Diabetes Self-‐Management Interven;on Among Adults with Type 2 Diabetes.” JAND 2012 • Yevvon YC, Wen-‐Bin C. “Means Yield to Ends in Weight Loss: Focusing on “How” vs “Why”
Aspects of Losing Weight Can Lead to Poorer Regula;on of Dietary Prac;ces,” JAND 2015 • Franz MJ, Boucher JL, et al. “Lifestyle Weight-‐Loss Interven;on Outcomes in Overweight
and Obese Adults with Type 2 Diabetes: A Systema;c Review and Meta-‐Analysis of RCT,” JAND 2015
• Celik S, Kayar Y. “Correla;on of Binge Ea;ng Disorder with Level of Depression and Glycemic Control in Type 2 DM Pa;ents,” General Hospital Psychiatry, 2015
• Racicka E, Brynska A. “Ea;ng Disorders in Children and Adolescents with Type 1 and Type 2 Diabetes – Prevalence, Risk Factors, Warning Signs,” Psychiatr. Pol.,2015.
• Nicolau J, Simo R. “Ea;ng Disorders are Frequent Among Type 2 Diabe;c Pa;ents and Are Associated with Worse Metabolic and Psychological Outcomes,” Acta Diabetol, 2015.
Questions & Conversation
Thank you for your ;me and alen;on!
Meg Salvia, MS, RD, CDE Walden Behavioral Care Meg Salvia Nutri;on megsalvia.com [email protected] @meg_salvia