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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 1 10/29/2015 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 2 10/29/2015 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 3 10/29/2015 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 4 10/29/2015 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. 5 10/29/2015 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? 6