Download Celiac Disease and Eating Disorders

Advanced Assessment and
Treatment Techniques for
Dietitians: Addressing CoOccurring Medical Conditions in
Eating Disorder Treatment
Stephanie Collins, RDN
Lead Nutrition Specialist
Huron Oaks Eating Disorder Recovery Program
Center for Eating Disorders
Lee McDonagh, RDN
Consultant Nutritionist, Center for Eating Disorders
Objectives
• Discuss the guidelines for Diabetes, IBS and
Celiac Disease that can contribute to an
eating disorder.
• Describe the unique physiological and
psychological challenges in treating an eating
disorder and chronic disease.
• Summarize best practices while working with
eating disorders and chronic illness.
Assessment for ED-DMT1
• Women with diabetes are at a 2.5 times
greater risk of developing an eating disorder.
• Overlapping factors that can contribute to an
eating disorder.
– Weight gain due to less glycosuria
– Higher BMI
– Decreased confidence and increased body
dissatisfaction
– Depression
– Perfectionism in self-management
Warning Signs for Anorexia
Nervosa and Diabetes
often missed!!
• Multiple episodes of DKA (Diabetic
Ketoacidosis)
• Decreased glucose monitoring
• Weight gain/loss
• Missed clinic appointments
• Heightened concerns about planning meals and
food choices
• Physical appearance
High Alert for Providers
DKA – raises the red flag!! Lack of insulin,
exercising more, restricted food choices
Hemoglobin A1C – average of previous 3
months glucose readings – high 9+
Goal 6 -8%
Insulin – omission
OTC medications
ER/Hospital visits – Insurance
Diabetes Management
Insulin – pen/pump
Food – meal planning, timing
Exercise – avoid DKA
Hypoglycemia
Social anxiety
Glucose monitoring 4-6 times daily
Insulin – the dreaded medication
Types of insulin
-Long acting
-Fast acting, regular
e.g. Lispro, Aspart,
glulisine (Apidra)
Administration of insulin
needle/syringe, pen or pump
Assess OTC medications, such as herbal
weight loss aids, laxatives.
MNT
Medical Nutrition Therapy
Food: Carbs, protein, fat –
Carb counting 15 grams/ carb choice
– Carb to Insulin ratio
Heart Healthy eating??
Meal planning
Meal/snack timing
UGH!!
Physical Exam
•
•
•
•
•
•
•
Dehydration
Diarrhea
Dry skin
Peripheral edema
Nausea, vomiting (gastroparesis)
Neuropathy – sensory or motor
Vision changes (non-proliferative to
proliferative retinopathy)
Retinopathy
Common ED symptoms
• Amenorrhea
• Hypothermia
• Perfectionism – perfect glucose numbers,
rituals, “rules” etc.
• Food restriction – especially carbs
• Self-harm
• Social interactions
• Depression
LISTEN!!
• Number 1 complaint of all patients
• Use Motivational Interviewing, CBT skills
• Negotiate a starting point for treatment.
– Diabetes and eating disorder management
• Referral to an Eating Disorder
psychotherapist.
• Dr. Ann Goebel-Fabbri
– “No studies have evaluated the
effectiveness of treatment.”
Goals for Team
• Safety of the client
• Stop the DKA – A1C <7% (gradual decrease
to avoid worsening retinopathy)
• Simplify the insulin regimen
• Lessen the complications – e.g. retinopathy
and neuropathy.
• Restore the nutritional status - > 19 BMI
• Psychotropic medication if necessary
AGE (Advanced Glycosylation)
Diabetes and Bulimia Nervosa
“Diabulimia”
•
•
•
•
Binging and purging main concern
Insulin needs are under or over-estimated
Hypoglycemia common
First step: 3 meals/3 snacks
– Avoid long periods without eating
– Administer insulin prior to meal/snack
Best Practices for Treating Eating
Disorders and Diabetes
• Stop the DKA!
• Use basal dose of insulin.
• Minimum 3 meals/3 snacks daily (snacks
negotiable and dependent on insulin dosing)
• Avoid food labels.
• All foods fit. Diet drinks, in moderation.
• Portions – guestimate! Hand Jive.
• Realistic glucose self-monitoring
• Consistent clinic/therapy attendance
Best Practices for Treating Eating
Disorders and Diabetes
• Address exercise and food requirements.
• Hypoglycemia – use glucose tabs/gel
• Gradually decrease glucose levels and HbA1c
1-2% per year. Tricor (fenofibrate)
• Type of insulin used depending on injection or
pump. 70/30 insulin maybe useful.
• Set small realistic goals with client, family,
and support team.
The Ultimate Goal: Honoring
Hunger/Fullness Intuitive Eating
• Starts with recognizing hunger
– Using scale of 1 to 10 with 1 being ravenous
and 10 being uncomfortably stuffed
– Goal: 4 to 6
• But with caveat to eat more or less as
desired
Confidence that you CAN do it!
Eating Disorders & Irritable Bowel
Syndrome
• IBS is strongly correlated to disordered
eating and psychological issues such as
anxiety and obsessive compulsive tendencies.
What is IBS?
Irritable Bowel Syndrome
• A complex digestive condition that occurs in
episodes characterized by symptoms of
abdominal pain, cramping, constipation or
diarrhea, bloating and gassiness.
• People with IBS have a sensitive digestive
tract in which diet and stress can play a role.
• Diet doesn’t cause IBS, but nutrition therapy
can reduce the symptoms.
How do we treat IBS?
• In the last 10 years we have learned that
fermentable, oligosaccharides, disaccharides,
monosaccharides and polys (FODMAPs) have
been identified as a group of short chain
carbohydrates that are rapidly digested and
poorly absorbed in the gut. They cause excess
fluid and gas in the bowels of many people
with IBS
What are FODMAPS?
• Naturally occurring carbohydrates
• High amounts of FODMAP = increase in IBS
symptoms
• Low FODMAP diet isn’t a cure but can provide
relief
• FODMAP diet NOT RECOMMENDED for
people with eating disorders
• Can exacerbate restrictive eating patterns
ED behaviors that may interrupt
normal digestion
Severe chronic restriction
Self induced purging
Laxative use
Excessive intake of caffeinated or
carbonated beverages
• Intake of artificial sweeteners
•
•
•
•
Other factors that affect GI
function
•
•
•
•
Gut microbata – digestive enzymes
Gut bacteria – probiotics
Stress
Anxiety
Managing Stress & Anxiety with
meals
• Healthy digestion, we need “rest and digest
state”
• Parasympathetic state - relaxed state, heart
rate and breathing slow down
• Parasympathetic state – promotes salivation,
stomach acid production, pancreatic enzymes
= digestion
• Helps balance flora in the intestines
Reduce anxiety before meals
•
•
•
•
Plan meals ahead
Eat in a relaxing and comfortable setting
Avoid the television, computer & phone
Take a moment to express gratitude
The RDN’s role with IBS
management
• Bridging the gap between GI symptom control
and eating disorder nutrition therapy.
• Identifying and modifying dietary triggers
when the ED is stable.
• Review family and personal history of GI
concerns.
• Identify specific GI symptoms.
The RDN’s role with IBS
management cont.
• Screen for ED behaviors like eating patterns,
laxatives, carbonated beverages, etc.
• Consider additional causes of GI symptoms
such as: anxiety and/or meds, visiting the
therapist?
• Refer to gastroenterologist with any alarming
features.
Medical Nutrition Therapy
Provide structured meal plan
Small frequent meals
Prevent triggering ED behavior
Encourage clients to limit artificial
sweeteners
• Monitor lactose and symptoms
• Adjust fiber and fluid
•
•
•
•
Medical Nutrition Therapy
• Low FODMAP fiber sources
• Fluid choices
• Suggest adjunctive therapies
Celiac Disease and Eating Disorders
• Celiac disease is an autoimmune disease
characterized by inflammation of the
intestinal lining in response to ingestion of
gluten, a protein found in the grain family.
• Affects 1% of the population but remains
largely undiagnosed and can have long term
morbidity.
Celiac Disease
• Symptoms include: gastrointestinal complaints
and weight loss
• Over 300 different symptoms documented
• Symptoms vary from person to person
• Chronic diarrhea, steatorrhea, abdominal
distension, vomiting, growth retardation and
fatigue
• Life-long autoimmune disease with no cure
Celiac Disease Treatment
•
•
•
•
Strict adherence to gluten free diet
Avoid: wheat, barley and spelt
More foods available recently
Many restaurants have gluten free options
Risks with Celiac Disease
• Required focus on food avoidance and
preoccupation with ingredients, increased risk
for ED
• Increased risk for depression
• Link between mental/behavioral disorders
with CD unclear
• Folic Acid, vitamin B6 and tryptophan may not
be absorbed.
Helping Clients with Celiac Disease
• Encourage eliminating gluten with meals
• Discourage counting calories/fat grams
• Avoid frequent weighing or numbers on the
scale
• Avoid eating patterns that include dieting,
ritualized behavior or secretive eating/binge
eating.
Resources
• Academy of Nutrition and Dietetics: Irritable
Bowel Syndrome. January 2014.
• Catsos, Patsy. Low FODMAP Diet. Food &
Nutrition Magazine. September/October
2016.
• Colton, Patricia. Eating Disorders in Girls and
Women with Type I Diabetes: A longitudinal
Study of Prevalence, Onset, Remission and
Recurrence. Diabetes Cares 2015
Jul:38(7)1212-1217.
• Custal, Nuria. Treatment Outcomes of
Patients with Comorbid Type I Diabetes and
Eating Disorders. BMC Psychiatry 2014
14:140-145.
Resources
• DCE Practice Group: Academy of Nutrition
and Dietetics.
• Practice Paper of the Academy of Nutrition
and Dietetics: Nutrition Intervention in the
Treatment of Eating Disorders. JADA
August 2011.
• Perspectives. Renfrew Center Foundation.
• Pocket Guide to Eating Disorders: Setnick,
Jessica, MS,RD,CSSD. 2011. American
Dietetic Association.
Resources
• Scarlata, Kate. Eating Disorders and GI
Symptoms, Understanding the Link between
them and how to treat patients. Today’s
Dietitian 2014 October Vol. 16 No. 10 P.14
• Satter, Ellyn, MS, RD, LCSW, BCD. The Joy
of Eating. Weight Management Matters. Fall
2011.
• SCAN Practice Group: Academy of Nutrition
and Dietetics.
• The Gluten Intolerance Group of North
America. Is Celiac Disease Putting You at Risk
for Disordered Eating?