Eating Disorders and Disordered Eating in Persons with Type 1

Diabetes (T1DM): Identification, Treatment, and Prevention

Barbara J. Anderson, Ph.D.Professor of Pediatrics

Baylor College of MedicineHouston, TX

Overview

Eating Disorders- definitions of psychiatric conditions

Disordered eating in the context of Type 1 Diabetes (T1DM)

Identifying, treating, and preventing disordered eating in pts. with T1DM

Psychiatric Eating Disorder Diagnostic Categories (DSM-

IV)

1. Anorexia Nervosa

2. Bulimia Nervosa

3. “Eating Disorder Not Otherwise Specified” (EDNOS): sub-clinical

diagnoses that do not meet all the diagnostic criteria

1. Anorexia Nervosa

Body weight <85% of normal Intense fear of gaining weight,

even though underwt. Disturbance in influence of body

weight or shape on self-evaluation Amenorrhea (absence of at least 3

consecutive menstrual cycles)

2. Bulimia Nervosa

Recurrent episodes of binge- eating (lack of control) 2X/wk.

Recurrent compensatory behavior –purging calories by self-induced vomiting; excessive exercise; medication misuse as with diuretics, laxatives, or insulin restriction.

Purging by Insulin Restriction

Called “Dia-bulimia” by the media; however this is not a medical diagnostic category and tends to trivialize 2 serious chronic diseases—diabetes and bulimia

Restricting or omitting insulin to purge calories

More frequent in women with T1DM than men

3. Eating Disorder Not Otherwise Specified (ED-

NOS) Disorders of eating that do not

meet strict criteria for Anorexia or Bulimia Nervosa but are clinically significant, disturbing physical and mental health and quality of life (QOL).

Sub-clinical, sub-threshold “disordered eating” also seen in T1DM with intermittent insulin restricting

Eating Disorder Diagnostic Categories (DSM-IV)

1. Anorexia Nervosa2. Bulimia Nervosa3. Eating Disorder Not

Otherwise Specified or EDNOS (a sub-clinical diagnosis) e.g., insulin restrictors who do not binge

MULTIPLE CONTRIBUTIONS TO DIAGNOSIS OF AN EATING

DISORDER

Wider Cultural Context— – U.S. research shows: 95% of women under 40

yrs. dissatisfied with their weight & shape; – >50% of 5th grade girls in Boston public

schools are on diets;

– Unrealistic weight and shape goals for young women in Westernized cultures; media preoccupation with the “perfect” body;

Genetic Factors – research shows genetic predisposition for anorexia

MULTIPLE CONTRIBUTIONS TO DIAGNOSIS OF AN EATING

DISORDER

Environmental & Family Factors—physical, sexual, and emotional abuse; dysfunctional family; activities that pressure persons to be thin (gymnastics, wrestling, ballet)

Psychological Factors —anxious obsessive-compulsive traits, depressive traits, addictive personality, often occurs with profound secrecy

HOW T1DM CONTRIBUTES TO DIAGNOSIS OF AN EATING

DISORDER-1

-Weight gain likely at diagnosis

-In pre-carb-counting era (Dx’d before mid-1990’s):

--Feelings of deprivation, shame,& punishment from food restrictions and rigid rules around eating

--“Learned perfectionism” around food and regimen

-Distress (depression) risk increases with diabetes diagnosis and management

HOW T1DM CONTRIBUTES TO DIAGNOSIS OF AN EATING

DISORDER-2

Unrealistic wt., BG, or behavioral goals in DM management

Feeling of being “damaged goods”

Gastro-paresis symptoms can “look like” and/or trigger an disordered eating

In the post-DCCT era, intensive regimen are emphasized, sometimes without regard for potential for wt. gain

Women with T1DM

At increased risk for eating disorders especially purging through insulin under-dosing or insulin omission.

Eating disorders are primarily about “feelings”, not about food.

Research by Polonsky, Anderson, et al., Diabetes Care,

1994 Not limited to younger women, of 341

women aged 13-60 yrs. 31% report intentional insulin omission.

Types of insulin omiters: 1. weight-related --associated with

medical risks—higher HbAlc, higher rates of retinopathy, more hospitalizations and ER visits

2. non-weight related –fear of hypoglycemia, also associated with medical risks

Reasons why patients with T1DM omit insulin

1. Direct purging of calories to manage weight

2. Fear of hypoglycemiaFear of embarrassing Sx. of low

BGDistress that I must eat when BG

is low

HYPOGLYCEMIA:THE LINK TO EATING

DISORDERS

“Causes me to binge”

“I Learn that keeping my BG > 300-- keeps me “safe”

“ I had to over-eat when my BG was really low, so now I just stuff myself when I feel that way….”

“The lower my BG the more I had ‘reactions’ so I ate and reduced my insulin to avoid this ‘feeling’. And I learned I could eat anything and as much of it as I wanted if I reduced my insulin……. “

Other reasons why patients with T1DM omit insulin

3. Anxiety around self-injecting, “needle phobia”

4. Attention (secondary gain), use medical emergency to avoid unsafe home (abuse?) and have support of medical staff

5. Belief that insulin causes complications (mainly with T2DM)

Research by Polonsky, Anderson, et al., Diabetes Care,

1994 Rates of omission peak in late teens,

early adulthood

44% believed taking insulin would cause weight gain

36% believed tight blood glucose control would cause them to be fat

10-year-Follow-Up Study(Goebel-Fabbri et al, 2008)

Significantly greater risk of diabetes complications in women who restricted insulin 10 years earlier vs. those who did not

Significantly greater risk of death in women who restricted insulin 10 years earlier vs. those who did not

T1DM Considerations

Weight loss at diagnosis is typical, followed by weight gain when insulin is started.

Fears that “insulin makes me fat” reinforced at diagnosis as well as when edema and weight gain follow periods of insulin omission.

Patients in intensive treatment arm of DCCT gained, on average, 10 lbs. Results of 9 yr. follow-up of these pts. “hard to lose wt.”

T1DM Considerations-2

Insulin dose increases during puberty, often not decreased after puberty.

Before “carbohydrate counting was recognized as a therapeutic tool for management of T1DM in 1994, restricted eating was the traditional medical treatment. There were “good foods” and “bad foods”.

Feelings of deprivation and punishment from food restrictions.

T1DM Considerations-3

Perfectionism around food and regimen behavior.

Distress with diet and regimen can lead to depression.

Unrealistic goals for weight and blood sugars and for self-care behavior.

Complex emotional consequences of T1DM – “Shame & blame syndrome” “damaged goods”, etc.

Pt. Who Omits Insulin for Weight Control: The Medical

Picture Increasing HbAlc despite insulin

adjustments, multiple daily injections prescribed.

Illogical blood sugar patterns

Erratic outpatient follow-up.

Weight loss in the context of non-dieting.

Pt. Who Omits Insulin for Weight Control: The Medical

Picture-2 Repeated, unexplained

hospitalizations/ER.

Patient refuses to share insulin injection responsibilities. Lots of secrecy.

Patient denies “missing shots”.

Pt. Who Omits Insulin for Weight Control: The Psychosocial Picture

Dissatisfaction with body & unrealistic weight goals present but not sufficient

Relationship problems: Attachments problems in family of

originLack of peer network and

problems in intimate relationships

Pt. Who Omits Insulin for Weight Control: The Psychosocial Picture-2 Overwhelmed and stressed about dm

mgt.

Symptoms of chronic high BG (which mimic Sx of clinical depression): fatigue, loss of energy & interests, flat affect.

Secretive about eating habits and regimen-related behaviors (shots, BGM)

Treatment of eating disorders in T1DM

Focus on this as a common “struggle” avoid blame/shame of pt.

Multidisciplinary team needed

Mental and physical health assessments for level of treatment needed

•Levels of Treatment for eating disorders in T1DM

Pt. must be medically stable (no ketosis) before referring to psychiatry

Endocrinologist must be involved at all levels.

Family involvement is needed

In-patient psych. for severe, long duration, life-threatening ED’s

Day Treatment Program

Outpatient therapy

Treatment of eating disorders in T1DM

Higher mortality associated ED Dx’s than any other psychiatric condition.

For women with ED and DM, risk of complications is significant (Rydall et al, New Engl Journ Med, 1997).

PREVENTION POINTS - #1

1. Promote realistic BG goals and behavioral goals to pt and parents.

2. Make it clear that perfectionism is not the goal in DM mgt.

3. Address wt. gain and intensive insulin therapy.

4. Prepare for sustained parental involvement in the tasks of DM mgt (insulin, BGM) that is acceptable to the child or teen and developmentally appropriate.

PREVENTION POINTS - #2

5. Recognize “strategic” insulin omission/misuse

—pt. learns just how little insulin to take to function or stay out of hospital

6. Recognize “ritualistic” insulin omission/misuse—pt. decides my body will gain weight if I take >12 units of Regular/Humalog

7. Discuss impact of wt. gain at diagnosis-pt. likely pleased with wt. loss before Dx—social reinforcement-After Dx, pt. may believe that “insulin causes wt. gain”

8. Avoid deprivation mindset about food

Summary

Clinicians must have a high “index of suspicion” when classic medical picture of an eating disorder appears in young female with T1DM. Remember: Secrecy is common in eating disorders.

Pts. with T1DM and disordered eating are at high risk for complications and mortality.

Summary-2

Demands multidisciplinary treatment, collaborate with mental health expert in eating disorders

Prevention is key!

DM Treatment Goals: Near normal glycemia Attention to carbohydrate counting (portion control & dietary restraint)

Perfectionism and frustration with blood

glucose ranges Weight gain associated with decreased A1c

Feeling deprived of food choices, dietary restraint and binge

eating cycle

Symptoms of depression

Negative feelings about weight and shape &

fear of further weight gain

Hyper-glycemia

Strategic insulin Omission

Model of the Inter-relationships between Type 1 Diabetes and Disordered EatingCopyright: 2002, Ann Goebel-Fabbri, Ph.D.

Joslin Diabetes Center