Eating Disorders Eating Disorders in Type 1 in Type 1 DiabeticsDiabetics

Deborah GreenUniversity of Bristol

ObjectivesObjectives Type 1 Diabetes

Pathophysiology Insulin functions

Eating disorders in diabetics - ‘Diabulimia’ Definition and development Signs and symptoms Patient views

Management options - Evidence based medicine

Miss E’s story

Type 1 DiabetesType 1 Diabetes• B cell destruction within the Islet cells leading to absolute insulin deficiency

• 90% of new diagnosis’ occur under the age of 30 years

(Image 1)

Insulin TherapyInsulin Therapy Insulin replacement remains the mainstay of treatment for type 1 diabetes

Converts glucose to glycogen to be stored in the

liverEnables glucose to be

transported into cells from blood

Increases glucose utilisation (glycolysis)

Vs

‘‘Diabulimia’Diabulimia’ Not officially recognised as an eating disorder

Omission of insulin

Glucose continues to circulate in the blood and is excreted in the urine

Body forced to obtain energy from fat and muscle stores RAPID WEIGHT

LOSS

Eating DisordersEating Disorders

‘Diabulimia’ – Omission of insulin by type 1 diabetics to prevent weight gain.

Prevalence Prevalence Eating disorders that meet DSM-IV

criteria, particularly bulimia nervosa and binge eating disorder, are more than twice as common in adolescent girls with Type 1 Diabetes than in their non-diabetic peers

(Nissim R et al, 2002)

Study of adolescent diabetics: 70% of girls with poor glycemic control omitted their insulin to compensate for over eating

(Greca et al, 2004)

Standard diabetes treatment goals:

• Good glycemic control• Attention to CHO counting

Encourages perfectionism

for optimal control and

weight

Weight gain associated with intensive insulin

therapy

Feeling deprived of food choices.

Binge eating develops

Depressive symptoms, poor

motivation for self care

Negative feelings about shape and fear of weight gain

What to look out What to look out forfor

Physical Psychological• Consistent hyperglycaemia and high HbA1C

• Irregular eating patterns (similar to BN)

• Extreme fatigue and weight loss

• Denial

• Thirst and polyuria • Distorted perception of body image

• Frequent DKA • Change in personality or mood swings

Long Term Long Term ComplicationsComplicationsRetinopathy

Neuropathy

What the patients What the patients say...say...

‘A small amount of milk and water on the test strip gives a normal reading. If mum gets suspicious I add fruit juice to make the reading higher...’

‘...I would rather be thin with kidney failure and retinopathy than fat and healthy...’‘I need to lose 15 pounds in 2 weeks to fit into my prom dress. I know I can do this if I skip my insulin...’

Evidence Based Evidence Based Medicine Medicine

Literature Search•Cochrane Database•Prodigy – NHS clinical knowledge

summaries•NICE Guidance - Eating Disorders • Journal Articles (www.library.nhs.uk)

• Goebel-Fabbri A. (2009) Disturbed eating behaviours and eating disorders in type 1 diabetes: Treatment recommendations

Evidence Based Evidence Based Medicine Medicine 1. NICE Guidance - Eating

Disorders(with concurrent physical conditions)

Screening for eating disturbances in patients who are not compliant

Close collaboration between psychiatric and diabetes teams

Evidence Based Evidence Based Medicine Medicine

1. NICE recommendations •Psycho-educationGOAL – to understand and manage psychiatric

illness in association with physical illness

RCT (n=212) showed improvement in eating disturbance but not glycemic control with psycho-education vs standard CBT therapy(Olmsted et al, 2002)

Limitations – recommendations grouped with BN

Evidence Based Evidence Based Medicine Medicine 2. Goebel-Fabbri A. (2009) Disturbed

eating behaviours and eating disorders in type 1 diabetes: Treatment recommendations

Family co-managementSmall, achievable goals

◦ Avoiding DKA’s◦ Regular meal patterns◦ Flexible, non-restrictive diet

Limitations – Recommendations based on professional experience. No formal outcome studies to date

Clinical Case – Clinical Case – Miss EMiss E•Type 1 diabetic omitting insulin

• Diagnosed aged 2 years• Parents very controlling over her diabetes• Felt individualised at school• Resented being different

• Admission to the Priory Hospital• 73% of ideal body weight – BMI = 14• Taking small amounts of basal insulin only• Food consumption very traumatic

The MDT Approach The MDT Approach Dietician • Aim for 3 meals daily – initially 300kcal/day in food• Weight gain achieved with FORTISIPS • Supervised table at meal times

Therapies (psychologist, therapies team) • Integrational activities – eating out, cooking, food shopping• Art and drama therapy – positive attitude to life • Psycho-education – family involvement

The MDT Approach The MDT Approach Diabetes Nurses• Matching fast-acting insulin dose to CHO portion sizes• Recognition of symptoms of hypoglycaemia and long term complications

ReflectionReflection Awareness of insulin omission as an inappropriate compensatory behaviour leading to eating disturbances and disorders

Early recognition in diabetic clinics

Multidisciplinary team involvement in treatment

Patient and family centred care – empowering people to take control of their own conditions

Personal Learning Personal Learning OutcomesOutcomes Obtaining an understanding of the

patient’s real concerns and worries

Not allowing personal attitudes towards an illness get in the way of your approach to treatment

‘If you are patient, you will get there in the end’ (Miss E, 2010)

ReferencesReferences1. Taki M et al. (1999) Differences between bulimia nervosa and binge eating disorder in

females with type 1 diabetes: the important role of insulin omission. J of Psychosom Res. 47(3) 221-31

2. Taki et al. (2002) Classification of type 1 diabetic females with bulimia nervosa into subgroups according to purging behaviour. Diabetes Care. 25(9): 1571-5

3. Nissim R et al. (2002) Eating disturbances in adolescent girls with type 1 diabetes mellitus. J of Psychosom Res. 141(10): 902-7

4. Olmsted M et al. (2002) The effects of psychoeducation on disturbed eating attitudes and behaviour in young women with type 1 diabetes mellitus. Int J of Eating Disorders. 32(2): 230-39

5. Scott J et al. (1998) Eating disorders and insulin dependent diabetes mellitus. Psychosomatics. 39: 233-43

6. Goebel-Fabbri A.E. (2009) Disturbed eating behaviours and eating disorders in type 1 diabetes: clinical significance and treatment recommendations. Current Diabetes Reports. 9: 133-9

7. Taylor D, Paton C, Kerwin R. (2008) The Maudsley Prescribing Guidelines 9 th Edition. Informa Healthcare. Eating disorders P433-6

8. NICE Guidance – Eating disorders: Core interventions in the treatment and management of anorexia nervosa, bulimia nervosa and related eating disorders. 2004.

9. www.diabetes.org.uk10. www.diabeteshealth.com11. www.timesonline.co.uk12. CAMS, The Delancy Hospital, Cheltenham13. The Priory Hospital, Bristol