Download - Eating Disorders in Type 1 Diabetics
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