Transcript Eating Disorders and Disordered Eating in Persons with Type 1

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 Medicine
Houston, TX
Overview
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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
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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
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Recurrent episodes of bingeeating (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
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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)
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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)
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2.
3.
Anorexia Nervosa
Bulimia Nervosa
Eating Disorder Not Otherwise
Specified or EDNOS (a subclinical diagnosis) e.g., insulin
restrictors who do not binge
MULTIPLE CONTRIBUTIONS TO
DIAGNOSIS OF AN EATING DISORDER
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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;
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Genetic Factors – research shows genetic
predisposition for anorexia
MULTIPLE CONTRIBUTIONS TO
DIAGNOSIS OF AN EATING DISORDER
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Environmental & Family Factors—physical,
sexual, and emotional abuse; dysfunctional
family; activities that pressure persons to be
thin (gymnastics, wrestling, ballet)
Psychological Factors —anxious obsessivecompulsive traits, depressive traits, addictive
personality, often occurs with profound
secrecy
HOW T1DM CONTRIBUTES TO
DIAGNOSIS OF AN EATING DISORDER-1
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-Weight
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gain likely at diagnosis
In pre-carb-counting era (Dx’d before mid1990’s):
--Feelings of deprivation, shame,& punishment
from food restrictions and rigid rules around eating
--“Learned perfectionism” around food and
regimen
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Distress (depression) risk increases with
diabetes diagnosis and management
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HOW T1DM CONTRIBUTES TO
DIAGNOSIS OF AN EATING DISORDER-2
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Unrealistic wt., BG, or behavioral goals in DM
management
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Feeling of being “damaged goods”
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Gastro-paresis symptoms can “look like”
and/or trigger an disordered eating
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In the post-DCCT era, intensive regimen are
emphasized, sometimes without regard for
potential for wt. gain
Women with T1DM
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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
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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 hypoglycemia
Fear of embarrassing Sx. of low BG
Distress that I must eat when BG is low
HYPOGLYCEMIA:
THE LINK TO EATING DISORDERS
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“Causes me to binge”
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“I Learn that keeping my BG > 300-- keeps me “safe”
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“ 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
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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)
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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
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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
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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
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Perfectionism around food and regimen behavior.
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Distress with diet and regimen can lead to depression.
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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
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Increasing HbAlc despite insulin
adjustments, multiple daily injections
prescribed.
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Illogical blood sugar patterns
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Erratic outpatient follow-up.
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Weight loss in the context of non-dieting.
Pt. Who Omits Insulin for Weight
Control: The Medical Picture-2
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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
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Dissatisfaction with body & unrealistic
weight goals present but not sufficient
Relationship problems:
Attachments problems in family of origin
Lack of peer network and problems in
intimate relationships
Pt. Who Omits Insulin for Weight
Control: The Psychosocial Picture-2
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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 regimenrelated behaviors (shots, BGM)
Treatment of eating disorders
in T1DM
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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
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Pt. must be medically stable (no ketosis) before
referring to psychiatry
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Endocrinologist must be involved at all levels.
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Family involvement is needed
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In-patient psych. for severe, long duration, lifethreatening ED’s
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Day Treatment Program
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Outpatient therapy
Treatment of eating disorders
in T1DM
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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
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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”
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Avoid deprivation mindset about food
Summary
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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
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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
Negative feelings about
weight and shape &
fear of further weight
gain
Symptoms of depression
Hyperglycemia
Strategic insulin
Omission
Model of the Inter-relationships between Type 1 Diabetes and Disordered Eating
Copyright: 2002, Ann Goebel-Fabbri, Ph.D.
Joslin Diabetes Center