Diabetes & Eating Disorders: A Complicated Relationship. Quinn Nystrom, M.S. Jenaca Beagley A.P.R.N., C.D.E.

Transcription

1 Diabetes & Eating Disorders: A Complicated Relationship Quinn Nystrom, M.S. Jenaca Beagley A.P.R.N., C.D.E.

2 Prevalence of Eating Disorders 75% of American women are dissatisfied with their appearance. 50% of 9 year old girls and 80% of 10 year old girls have dieted. At least 4% of teenage girls and college-age women become anorexic or bulimic. Steinhausen HC: The outcome of Anorexia Nervosa in the 20 th century. Am J Psychiatry 159: ,2002. Anorexia Nervosa and Bulimia Nervosa- Diagnosis & Treatment Guide for Professionals 2

3 Eating Disorders + Diabetes ED behaviors seen in 8% of T1DM vs 1% of peers without DM. Increased risk of disturbed eating behavior in girls with T1DM as young as % of females with type 1 diabetes have some form of disordered eating or weight control behavior. 36% reported intentional omission of insulin. Strong association between type 2 diabetes and clinically significant binge eating. Colton P et al, Eating disorders in girls and women with type 1 diabetes: A longitudinal study of prevalence, onset, remission and recurrence. Diabetes Care 38: ,July 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 study Diabetes Care 27: , 2004 Udo et al. Menopause and metabolic syndrome in obese individuals with binge eating disorder. Eat Behav 2014;15 3

4 What is ED-DMT1? The dual diagnosis of an eating disorder and type 1 diabetes is often referred to as diabulimia, however this is not a medically recognized term and it is not an accurate description. Among some academics, the nomenclature eating disorders in diabetes mellitus type 1 (ED- DMT1) is used to denote the spectrum of disturbed eating behavior found within this specific demographic. Jacqueline Allen, Birkbeck University

5 Why higher risk? Feels betrayed by body with diagnosis of diabetes. Emphasis on food and dietary restraint. Society setting food rules for people with diabetes. Diabetes management focuses on numbers. Patient judges self being "good" or "bad" based on eating patterns or blood glucose level. Belief that you ate your way into diabetes. Weight gain/higher BMI, result from intensive insulin therapy. Temptation factor Easy availability of deliberate insulin omission to control weight. Effect of diabetes on self-concept, body image, and family interactions. Family dynamics involving autonomy and independence concerning diabetes self-management. Diabetes Spectrum volume 22, Number 3, ,160, 2009 Mitchell, J. Medical comorbidity and medical complications associated with Binge-eating disorder. Int J Eat Dis 49:3 5

6 Increased Morbidity Disordered eating behavior at baseline was associated with retinopathy just 4 years later. Disordered eating is 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: ,

7 Increased Mortality Anorexia has the highest mortality rate (up to 10%) of any psychiatric diagnosis Anorexia combined with T1D, mortality rates are much higher (~28%) Insulin restriction is associated with: Shorter lifespan Mean age of death = 45 years vs. 58 years Increased mortality More than threefold increase in the relative risk of death during the 11-yr study period. Goebel-Fabri, A. et al. Insulin restriction and associated morbidity and mortality in women with type 1 diabetes. Diabetes Care, 31(3),2008 Mortality in Concurrent Type 1 Diabetes and Anorexia Nervosa Diabetes Care 2002; 25:

8 My story

9 AGE 13

10 Blood glucose meter Blood glucose test strips Blood ketone meter and blood ketone strips OR urine ketone strips Lancing device Lancets Continuous Glucose Monitor & Sensor Alcohol swabs Syringes Insulin pump supplies Batteries Glucose tablets or other quick acting source of sugar Glucagon kit Waterproof tape Adhesive remover Frio cooling wallet Snacks

11 National Youth Advocate 11

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18 ED-DMT1 Diagnosis Treatment: Outpatient Inpatient Treatment Residential Treatment 18

19 Graduate School Research Diabetes Daze: How Adolescent Patients are Affected by Messaging Illness Perception Social Learning Theory Peer, Media, Medical Professional & Parental Messages

20 Results Not all adolescents had optimum control of their diabetes currently (45 percent were at 8.1 percent or higher for their A1c). Nearly 97% agreed that better diabetes management would allow them to live longer. Adolescents place their greatest information source with diabetes medical professionals. Negative messages came from multiple sources.

21 Results 75% told of a person having misinformation % reported that they had a negative experience where they were called overweight. 71% say a motivating factor in improving selfmanagement is curability/controllability.

22 ED Screening Tools for Diabetes Patients Diabetes and Eating Problem Survey Revised (DEPS-R) SCOFF

23 DEPS-R 16 questions 0-5 Likert scale, can complete in <10 min Some examples of questions specifically related to diabetes: I feel fat when I take all of my insulin. Other people tell me to take better care of my diabetes. After I overeat, I skip my next insulin dose. * ADD the total score = greater than 20 is clinically significant. Markowitz, J., Butler, D.,Volkening, L., Antisdel, J., Anderson, B., Laffel, L., Brief screening tool for disordered eating in diabetes. Diabetes Care,vol. 33, number 3, MARCH 2010

24 SCOFF Do you make yourself Sick because you feel uncomfortably full? Do you worry you have lost Control over how much you eat? Have you recently lost more than One stone (7.7 kg, about 15 lbs) in a 3 month period? Do you believe yourself to be Fat when others say you are too thin? Would you say that Food dominates your life? *One point for every yes; a score of 2 indicates a likely case of anorexia nervosa or bulimia

25 Medical Complications Long list of medical problems associated with eating disorders Most are reversible and treatable Some are associated with permanent harm In anorexia and ARFID a direct result of starvation and weight loss In bulimia directly correlated with mode and frequency of purging Mehler, Phillip (2010) Eating Disorders a guide to medical care and complications

26 Refeeding Syndrome Disorder discovered This syndrome was first observed and described after World War II when victims of starvation were noted to experience cardiac or neurologic dysfunction or both after being reintroduced to food. Electrolyte disturbances (primarily decreased levels of phosphorus, magnesium, or potassium) occur immediately upon the rapid initiation of refeeding commonly within 12 or 72 hours and can continue for the next 2 to 7 days. Cardiac complications can develop within the first week, often within the first 24 to 48 hours. 3 Yantis M, Velander R. How to recognize and respond to refeeding syndrome. Nursing 2008; 38(S):34-39

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28 Criteria from the guidelines of the National Institute for Health and Clinical Excellence for identifying patients at high risk of refeeding problems (level D recommendations*) Either the patient has one or more of the following: Body mass index (kg/m 2 ) <16 Unintentional weight loss >15% in the past three to six months Little or no nutritional intake for >10 days Low levels of potassium, phosphate, or magnesium before feeding Or the patient has two or more of the following: Body mass index <18.5 Unintentional weight loss >10% in the past three to six months Little or no nutritional intake for >5 days History of alcohol misuse or drugs, including insulin, chemotherapy, antacids, or diuretics

29 How to avoid re-feeding syndrome? Recognize the patient at risk Carefully test for and correct electrolyte abnormalities before initiating any nutritional support. Judiciously restore circulatory volume, closely monitor vitals and exam, Never administer rapid IV fluids Increase caloric delivery slowly (but faster than before) Carefully monitor the electrolytes especially over the 1st week including: Phosphorous, Potassium and Magnesium

30 Potential Complications and Treatment Electrolyte abnormalities Blood chemistry daily or every other day until stable, replace low Fluid shift Edema Lung and edema checks, compression hoes, elevate feet, medication Vital sign changes (HR) Monitor vital signs daily Sluggish GI tract Dietary low and slow(not as low as before) Fiber and hydration

31 Pseudo-Bartter s syndrome/ secondary hyperaldosteronism Carrie Brown, MD Electrolyte Abnormalities in Severe Eating Disorders. ACUTE annual symposium 2017.

32 Complications of Pseudo-Bartter s EDEMA PREVENTION Spironolactone

33 Treatment and Recovery: it s a process Multidisciplinary team Diabetes informed treatment combined with standard ED treatment techniques/therapies Intuitive eating diabetes creates a challenge Perfectionism attainable glucose target goals Medical concerns Insulin edema discuss at the beginning of treatment until resolved Ann Goebel-Fabbri (2017) Injecting Hope Prevention and recovery from eating disorders in diabetes *slides 79-83

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35 For Family and Friends Practical Applications Know warning signs of ED and symptoms of DKA Refrain from fear tactics or shaming End body talk Encourage flexible eating Ann Goebel-Fabbri (2017) Injecting Hope Prevention and recovery from eating disorders in diabetes

36 For Mental Health Providers Practical Applications Gather diabetes history Diagnosis, family s response, relationship with providers Expectations, targets for glucose and approach to food. Adapt your standard approach to eating disorders Diabetes specific concerns need to be integrated into treatment Perfectionism : diabetes management, food, weight Comfort level - burnout

37 Diabetes Providers Practical Applications Create a nonjudgmental treatment relationship. Language: Management vs. control check/value vs. test (glucose or A1c) Like a compass not a report card High/low or in target vs. good/bad Avoid labeling food as good or bad Avoid suggestions or comments that diminish the complexity and difficulty of having both DM and ED just eat Just take your insulin Avoid labels non-compliant Ann Goebel-Fabbri 2017 Injecting Hope Prevention and Recovery from Eating Disorders in Type 1 Diabetes

38 Diabetes Providers Practical Applications Take the fear of weight gain seriously Help cope with edema Teach symptoms of DKA Gradual decreases in A1c Focus on where the pt. feels ready Celebrate small successes Ann Goebel-Fabbri 2017 Injecting Hope Prevention and Recovery from Eating Disorders in Type 1 Diabetes

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40 Contact us: Jenaca Beagley, M.S.N., A.P.R.N., NP-C, C.D.E. Quinn Nystrom, M.S.