Download Diabetes and Eating Disorders

10/29/2015
Disclosures

 No conflicts of interest
Jenaca Beagley, MSN, APRN, NP-C, CDE
DIABULIMIA

 NON-MEDICAL term used widely in popular
media.
 The intentional misuse of insulin to control weight
 Hyperglycemia resulting in glucose excretion in the
urine in a sense calories are “purged” hence the term
“diabulimia”
Anorexia Nervosa

 primarily affects adolescent girls and young women.
 characterized by distorted body image
 No pertinent financial disclosures
The dual diagnosis of
ED and DM

Anorexia Nervosa
~
Bulimia
~
ED NOS
“It is important for diabetes educators to have a general
understanding of eating disorders and diagnostic
criteria to help identify patients with or at risk for
developing them.”
Diabetes Spectrum June 20, 2009 vol. 22 no. 3 159-162
Bulimia Nervosa

 Characterized by frequent episodes of binge eating
followed by inappropriate behaviors such as self-induced
vomiting to avoid weight gain. Binge eating and
compensatory behaviors must be exhibited once a week.
 excessive dieting that leads to severe weight loss(less than 85%
IBW) with a pathological fear of becoming fat.
Amenorrhea x 3 months
 Purging type – self induced vomiting, laxatives, diuretics,
or enemas.
 Binge/purge or restrictive types
 Non-purging type – over exercise or fasting

DSM American Psychiatric Publishing
 DSM American Psychiatric Publishing
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ED - NOS

 A broad grouping of disorders that do not meet
diagnostic criteria for Anorexia or Bulimia.
 ie: Binge eating disorder, variants of bulimia –
binge/purge less often, meet criteria for anorexia but
is normal WT or have regular menses, purging after
eating small amounts of food, chewing/spitting,
milder subthreshold variants.
 Most people with ED & Type 1 Diabetes will be in the
ED-NOS category
Definition of ED-DMT1

 The term used by health care professionals for
“diabulimia”
 Diagnosed when a person intentionally misuses insulin to
control weight.
 Decreasing insulin intake
 Avoiding any insulin
 Suspending pump, using basal but not covering for carbs
 Waiting longer to take the right amount of insulin
 Tampering with the insulin so it doesn’t work properly
 Heat exposure, microwaving, injecting into areas of atrophy or
indurations
 Dr. Ovidio Bermudez – “11 Facts About Diabulimia You Should
Know” www.empowher.com
Epidemiology - summary

Prevalence of ED

 75% of American women are dissatisfied with their
appearance.
 50% of 9 yr old girls and 80% of 10 yr old girls have dieted.
 At least 4% of teenage girls and college-age women become
anorexic or bulimic.
 Anorexia has the highest mortality rate (up to 10%) of any
psychiatric diagnosis.
 Steinhausen HC: The outcome of Anorexia Nervosa in the 20th
centur. Am J Psychiatry 159:1284-1293,2002
 Anorexia Nervosa and Bulimia NervosaDiagnosis & Treatment Guide for Professionals
Who is at risk?

 Women 10-25 yrs old.
 Type 1 Diabetes
 Increased risk of disturbed eating behavior in girls with T1DM as
young as 9 yrs old.
 Full syndrome or sub-threshold ED in 8% of T1DM vs 1% of
controls
 25% - 32.4% of females with Type 1 diabetes have some form of
disordered eating or weight control behavior
 30-36% reported intentional omission of insulin
 Colton P et al, Eating disorders in girls and women with type 1 diabetes: A
longitudinal sutdy of prevalence, onset, remission and recurrence. Diabetes
Care 38:1212-1217, 2015
 Peveler RC. Type 1 Diabetes & Eating Disorders, Diabetes Care 2005
 Colton P. et al, Disturbed eating behavior and eating disorders in preteen
and early teenage girls with type 1 diabetes; a case-controlled stud
Diabetes Care 27:1654-1659, 2004
Eating Disorders and Diabetes Model

 Increased prevalence of sub-threshold and full
syndrome eating disorders in females with Type 1
DM
 Insulin omission or reduction starts early, pre-teens.
 It increases as age advances through adolescence and
college years.
 Significant relationship between disordered eating
habits, insulin misuse, and microvascular
complications.
Goebel-Fabbri, A. et al, Identification and treatment of eating disorders in women
with type 1 diabetes mellitus, Treatments in Endocrinology, 1(3):155-62, 2002
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Increased Morbidity

 Poor glycemic control
rapid acceleration of diabetic
complications
 Increased risk of DKA
 Hospitalizations
 Acceleration of diabetes related complications  Retinopathy and neuropathy
 Poor metabolic control and blood lipid abnormalities can
independently increase the risk of long-term complications
affecting multiple body systems
Increased Morbidity

 Disturbed eating behavior at baseline
3x rate of retinopathy 4 years later. More
predictive of retinopathy than duration of diabetes
alone.
Rydall AC et al: Disordered eating behavior and microvascular complications in young
women with insulin dependent diabetes mellitus. N Engl J Med 336:1849-1854, 1997
 Diabetes Spectrum, vol 22, 3, 2009
 Goebel-Fabri, A. et al. Insulin restriction and associated
morbidity and mortality in women with type 1 diabetes.
Diabetes Care, 31(3),2008
Increased Mortality

 Insulin restriction is associated with shorter lifespan
Why are those with DM
at increased risk for ED?

 Emphasis on food and dietary restraint
 Weight gain/higher BMI, result from intensive insulin therapy
 Increased mortality
 Temptation facor -Easy availability of deliberate insulin omission to
control weight
 Effect of diabetes on self-concept, body image, and family interactions
 Goebel-Fabri, A. et al. Insulin restriction and associated
morbidity and mortality in women with type 1 diabetes.
Diabetes Care, 31(3),2008
 Family dynamics involving autonomy and independence concerning
diabetes self-management
 Diabetes Spectrum volume 22, Number 3,138-141,160, 2009
Case Presentation

• “Liz” is a 14 yo female dx DMT1 at age 13
• On MDI – insulin pens. (has an omnipod and a
dexcom at home she has never used)
 received attention after loosing wt and was
diagnosed with diabetes. Started to send
inappropriate selfies to friends. Manipulated insulin
by bending needles. Added “drop” of insulin to
blood to manipulate blood sugar readings.
Case presentation cont…

•
•
•
•
•
•
Admit wt 132 – BMI 20.7
A1c 15%
U/A : glucose 3+, ketones 2+
CMP WLN except glucose 316
Mag 1.7
Vital signs WNL
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Case presentation cont…

 BG much improved over course of treatment;
some variation when she had “family style” meals
where she self plated or chose “extras/challenges” and
did not dose insulin for these.
 Weight gain 5 lbs – metformin off label use
 A1c 12.5% at discharge (5 weeks)
Screening Tools

 Eating Attitudes Test
 Diagnostic Survey for Eating Disorders
 Diabetes Spectrum, 22, 143-146, 2009
 Diabetes Eating Problem Survery-Revised (DEPS-R)
 Hanlan, M., Griffith, J., Patel, N., Jaser, S., Eating
disorders and disordered eating in type 1 diabetes:
prevalence, screening, and treatment options.
Curr Diab Rep, 13:909-916, 2013.
Recognizing ED in DM

 Overall deterioration in psychosocial functioning (school,
work, interpersonal relationships)
 Increasing neglect of diabetes management/worsening
metabolic control
 Erratic clinic attendance
 Significant weight gain or weight loss
 Increased concerns about meal planning/food
composition
 Poor body image/low self esteem
 Depressive symptoms
 Multiple episodes of DKA (repeated and unexplainable)
Screening questions

 Don’t be afraid to ask!
 Do you ever adjust your insulin to influence your
weight?
 Do you have a regular menstrual cycle?
 Do you take less insulin than you should?
Goebel-Fabri, A. et al. Insulin restriction and associated morbidity and
mortality in women with type 1 diabetes. Diabetes Care, 31(3),2008
 “Have you ever been overweight?”
 This one question yielded 83% sensitivity and 94% negative
predictive value for the presence of disordered eating in
adolescents with type 1 diabetes.
Curr Diab Rep, 13:909-916, 2013.
Intervention/manageme
nt

 “Early intervention is critical in this population in
order to maintain optimum health status and
decrease the chances of complications…”
 “With consistent and early screening, those most
vulnerable to develop eating disorders or disordered
eating behaviors may receive timely and appropriate
treatment.”
Intervention/manageme
nt

 All patents with T1DM who are diagnosed with ED
should be considered for in hospital stabilization or
ED inpatient treatment due to the high morbidity
and increased mortality risk.
 Medical assessment
 Psychiatric assessment
 Formalize diagnosis of ED-DMT1
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Management steps

 “ASSUME then RESUME”
 1. all care assumed by staff
 2. Joint care by staff and patient
 3. Care resumed by the patient, as they gradually
wean from staff supervision (transition from in pt,
residential, to PHP, out pt treatment)
Management steps

 Consistency
 Protocols for insulin management and BG testing
 Initially aim for modest glucose control and then
gradually aim for tighter control
“A blood glucose target range in the 200’s is a good place
to start”
 Set realistic/achievable goals – focus on improvements.
Look at BG ave 7,14,30 or frequency of checking.
 Multi-disciplinary TEAM
Critchley, S., Meier, M., Taylor, D., Eating disorders and type 1 diabetes
practical approaches to treatment.
Practical Diabetology, March/April 2014
ED treatment

 Multi - disciplinary team
 CBT – cognitive behavioral therapy
 Develop healthier means of coping with negative
emotion
 Decrease perfectionism or black/white thinking
 Establish regular, flexible eating patterns, and
eliminating dieting and food restriction.
ED-T1DM Challenges and
Treatment strategies

Critchley, S., Meier, M., Taylor, D.,
Eating disorders and type 1 diabetes practical approaches to treatment.
Practical Diabetology, March/April 2014
•Acceptance of DM and/or ED
- ongoing discussion about
acceptance being a journey.
DM complications can get worse with
better diabetes care
- Set higher BG target (200’s)
- - if complications are present,
encourage treatment by
appropriate specialist and
make recommendations for
medications etc.
(3 meals, 3 snacks to not trigger binge and establish routine)
Murphy,R., Straebler, S., Cooper, Z., and Fairburn, C.,
Psychiatr Clin North Am. Sep; 33(3): 611–627. 2010
Cognitive Behavioral Therapy for Eating Disorders
Challenges and Treatment strategies
Continued….
Moodfluctuations

*Reviewbloddglucosereadings,thenexploreother
potentialreasons.
BMIisnotalwayslow;patientsandproviderdon’t
alwaysthingofED
*OngoingdiscussionregardingwhyED‐T1DMisan
eatingdisorder,althoughitisdifferentfromothereating
disorders.
Mythsandbeliefsaboutdiabetescare
*Keepdispellingmythsandoldbeliefswithfactsand
currentdiabeteseducation
Conflictingmessagesfromdifferentspecialtyareas
*AcknowledgethemanddiscussrealityversesED
thoughts(e.g.dessertsforpeoplewithdiabetes,sugar‐
freeproducts,fatsare“bad”
- Psychiatrist involvement for
medications, documentation of consistent
medications
Comorbid conditions: depression,
anxiety, OCD, etc.
Challenges and Treatment strategies
Continued….
Insulin+food=fat

Hyperglycemia(insulinwithholdingor
overeating)
Hypoglycemia(fear,struggletotreatwith
food)
Edema
*Educateonwhythebodyneedsinsulin
andthatinsulinisnottheenemy.
*slowreductionofBGlevels
*HigherBGtargetgoals,initially
*Reinforceketonetestingandtreatment
*Reviewpt’sbackgroundforexcessive
insulin
*insulinadjustmentsmustbemade
frequentlyandincrementallysonoteating
toinsulindose.
*useglucosetabstotreatlowsfor
consistencyandtokeepseparatefrom
mealplanandhelpfromtriggeringbinges.
*startslowlywithincreasinginsulin
doses.
*Acknowledgeandchallengethethought
of“feelingfat”
*Keepstressingthatedemawillimprove
withconsistentdiabetescare.
*Encourageactivityastolerated.
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Challenges and Treatment strategies
Continued….

Weightgain
Malnutritionorover‐nutrition
Focusonnumbers
*Acknowledgeanddiscusswhat
canbeexpected.
*Provideongoingtherapy
regardingchallengesandroad‐
blockswithbodyimage.
*Establishhealthyweightrangeand
discusswiththept atappropriate
time
*Adjustmeal‐plangoalsbasedon
weightstatus.
*Acknowledgethatalwayshavingto
lookatnumbersisverydifficult
*EmphasizethatnumbersareDATA
not“judgments”
Resources/specialists

Center for change
801-224-8255 (inpt, residential, php,
outpt treatment)
Insert list of local therapists/doctors
specializing in ED
Challenges and Treatment strategies
Continued….

GIproblems(e.g.,gastroparesis, *GIspecialistmayneedtobe
celiacdisease)
involved.
*Pt’swillneedtobetaught
celiacdiet
*gatroparesisiscommoninED
+DMcomplication
Recoverytime/burnoutof
*ProvidersshouldnottreatED‐
providers
T1DMalone,butwithateam
approach.Thisincludes
psychologist,dietitian,CDE’s,MD,
endocrinologist.
Eating Disorder Resources for
Diabetes Educators
(besides sited sources in slides)

 List of publications and programs Table 2:
Diabetes Spectrum 22 (3) 2009
 DBI (Diabetes Behavioral institute)
 Ann Goebel-Fabbri.com
 Monthly blog “weighty matter”
 DBI Youtube “Eating Disorders and Diabetes: Diabulimia and Beyond”
https://www.youtube.com/watch?v=Ztsdc7PejJY
Questions?

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