Jenaca Beagley, MSN, APRN, NP-C, CDE Michelle Smith, MSN, APRN, NP-C

Transcription

1 Jenaca Beagley, MSN, APRN, NP-C, CDE Michelle Smith, MSN, APRN, NP-C 1

2 Basic review of Type 1 diabetes Pathophysiology Standards of medical care Overview of Eating Disorders ED-DMT1 Who is at risk for DMT1 and ED? Screening Overview Intervention/management Challenges and treatment options Case studies 2

3 Type 1 Diabetes introduction Prevalence: 29.1 million Americans have diabetes 5% of those diagnosed with diabetes have Type 1 Approximately 1.25 million American children and adults have type 1 diabetes. National Diabetes Statistics Report 2014

4 Type 1 Diabetes introduction Usually occurs in childhood/adolescence Most people under the age of 20 juvenile diabetes Caused by a cell-mediated immune response Destroys the insulin producing - cells of the pancreas

5 Pathophysiology How things normally work When you eat, your body breaks food down into glucose. Glucose is a type of sugar that is your body s main source of energy.

6 Pathophysiology How things normally work As blood glucose rises, the body sends a signal to the pancreas, which releases insulin.

7 Pathophysiology How things normally work Acting as a key, insulin binds to a place on the cell wall (an insulin receptor), unlocking the cell so glucose can pass into it. There, most of the glucose is used for energy right away.

8 Pathophysiology How things normally work Some glucose is stored by the liver for later use.

9 Pathophysiology Blood glucose regulation As your blood glucose rises (after a meal), the pancreas releases insulin. When your blood glucose is low (between meals) your liver releases glucose.

10 Pathophysiology In a person with diabetes, levels tend to run high, and may vary dramatically. In a person without diabetes, levels stay within normal limits. blood glucose levels

11 Pathophysiology Type 1 diabetes Your pancreas has stopped or nearly stopped making insulin (insulin deficiency). Since you have suddenly lost your insulin keys, you have no way to unlock your body s cells and allow glucose to enter.

12 Symptoms of Diabetes/Hyperglycemia

13 OR OR OR Type 1 Diabetes diagnostic criteria FPG 126 mg/dl (7.0 mmol/l). Fasting is defined as no caloric intake for at least 8 h. 2-h plasma glucose 200 mg/dl (11.1 mmol/l) during an OGTT. The test should be performed as described by the World Health Organization, using a glucose load containing the equivalent of 75 g anhydrous glucose dissolved in water.* A1C 6.5% (48 mmol/mol). The test should be performed in a laboratory using a method that is NGSP certified and standardized to the DCCT assay.* In a patient with classic symptoms of hyperglycemia or hyperglycemic crisis, a random plasma glucose 200 mg/dl (11.1 mmol/l). Standards of Medical Care in Diabetes 2016, American Diabetes Association

14 Prevalence of ED 75% of American women are dissatisfied with their appearance. 50% of 9 yr old girls and 80% of 10 yr old girls have dieted. At least 4% of teenage girls and college-age women become anorexic or bulimic. Anorexia has the highest mortality rate (up to 10%) of any psychiatric diagnosis. Steinhausen HC: The outcome of Anorexia Nervosa in the 20 th centur. Am J Psychiatry 159: ,2002 Anorexia Nervosa and Bulimia Nervosa- Diagnosis & Treatment Guide for Professionals 14

15 The dual diagnosis of ED and DM Anorexia Nervosa Bulimia OSFED (Other Specified Feeding or Eating Disorder ) 15

16 ED-DMT1 vs. DIABULIMIA Diabulimia is a NON-MEDICAL term used widely in popular media for ED-DMT1 Intentional misuse of insulin to control weight Hyperglycemia results in glucose excretion in the urine, therefore calories are purged hence the term diabulimia Diabetes Spectrum volume 22, Number 3, ,160,

17 Clinical features of ED-DMT1 Usually diagnosed when a person intentionally misuses insulin to control weight. Decreasing insulin doses Complete insulin omission Delaying to take the right amount of insulin Tampering with the insulin or insulin delivery device so it doesn t work properly Heat exposure, injecting into areas of atrophy or indurations, suspending or tampering with insulin pump or needles. Diabetes Spectrum volume 22, Number 3, ,160,

18 Who is at risk for ED-DMT1? Increased risk of disturbed eating behavior in girls with T1DM as young as 9 yrs. old. ED behaviors seen in 8% of T1DM vs. 1% of peers without DM 32.4% of females with Type 1 diabetes have some form of disordered eating or weight control behavior 36% reported intentional omission of insulin Colton P et al, Eating disorders in girls and women with type 1 diabetes: A longitudinal sutdy 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: ,

19 Increased Morbidity Retinopathy Neuropathy Poor metabolic control and blood lipid abnormalities can independently increase the risk of long-term complications affecting multiple body systems Increased risk of DKA Hospitalizations Diabetes Spectrum volume 22, Number 3, ,160, 2009 Goebel-Fabri, A. et al. Insulin restriction and associated morbidity and mortality in women with type 1 diabetes. Diabetes Care, 31(3),

20 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: ,

21 Increased Mortality 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),

22 Why are those with DM at increased risk for ED? Emphasis on food and dietary restraint 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,

23 Eating Disorders and Diabetes Model Goebel-Fabbri, A. et al, Identification and treatment of eating disorders in women with type 1 diabetes mellitus, Treatments in Endocrinology, 1(3):155-62,

24 Recognizing ED in DM Overall deterioration in psychosocial functioning (school, work, interpersonal relationships) Increasing neglect of diabetes management/worsening metabolic control Erratic clinic attendance Significant weight gain or weight loss Increased concerns about meal planning/food composition Poor body image/low self esteem Depressive symptoms Multiple episodes of DKA (repeated and unexplainable) 24

25 Screening Tools Diabetes Eating Problem Survey-Revised (DEPS-R) 16 questions 0-5 Likert scale, can complete in <10 min 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 Hanlan, M., Griffith, J., Patel, N., Jaser, S., Eating disorders and disordered eating in type 1 diabetes: prevalence, screening, and treatment options. Curr Diab Rep, 13: ,

26 DEPS-R questions (specific to diabetes and ED) 1. Losing weight is an important goal to me. 2. I skip meals and/or snacks. 3. Other people have told me that my eating is out of control. 4. When I overeat, I don t take enough insulin to cover the food. 5. I eat more when I am alone than when I am with others. 6. I feel that it s difficult to lose weight and control my diabetes at the same time. 7. I avoid checking my blood sugar when I feel like it is out of range. 8. I make myself vomit. 26

27 DEPS-R questions 9. I try to keep my blood sugar high so that I will lose weight. 10. I try to eat to the point of spilling ketones in my urine. 11. I feel fat when I take all of my insulin. 12. Other people tell me to take better care of my diabetes. 13. After I overeat, I skip my next insulin dose. 14. I feel that my eating is out of control. 15. I alternate between eating very little and eating huge amounts. 16. I would rather be thin than to have good control of my diabetes. 27

28 Intervention/ management Early intervention is critical in this population in order to maintain optimum health status and decrease the chances of complications With consistent and early screening, those most vulnerable to develop eating disorders or disordered eating behaviors may receive timely and appropriate treatment. Curr Diab Rep, 13: ,

29 Intervention/ management Medical and Psychiatric assessment Formalize diagnosis of ED-DMT1 29

30 Management steps 3 Phase approach 1. Staff assume all diabetes care. 2. Patient assumes more responsibility with staff supervision. 3. Full care resumed by the patient with appropriate staff supervision. Patient becomes more independent. 30

31 Management steps Consistency Protocols for insulin management and BG testing Multi-disciplinary TEAM approach Psychiatrist, therapist, RD, RN, NP, MD, endocrinologist, etc. Critchley, S., Meier, M., Taylor, D., Eating disorders and type 1 diabetes practical approaches to treatment. Practical Diabetology, March/April

32 Diabetes Management Insulin replacement regimen Long-acting + rapid-acting (basal-bolus or physiologic insulin) Preferred for most patients because: Closely mimics natural physiologic insulin production Lowers risk of hypoglycemia Simplifies meal planning

33 Glycemic targets modest glucose control tighter control Symptomatic relative hypoglycemia Usually. A blood glucose target range in the 200 s is a good place to start - Critchley, S., Meier, M., Taylor, D., Eating disorders and type 1 diabetes practical approaches to treatment. Practical Diabetology, March/April Bermudez, O., Gallivan, H., Lesser, J., Meier, M., Parkin, C., Inpatient Management of Eating Disorders in Type 1 Diabetes. Diabetes Spectrum 33 22,3,

34 Table 5.2 Summary of glycemic recommendations for nonpregnant adults with diabetes A1C < 7.0% (53 mmol/mol)* Preprandial capillary plasma glucose mg/dl* ( mmol/l) Peak postprandial capillary plasma glucose <180 mg/dl* (10.0 mmol/l) Standards of Medical Care in Diabetes 2016, American Diabetes Association *More or less stringent glycemic goals may be appropriate for individual patients. Goals should be individualized based on duration of diabetes, age/life expectancy, comorbid conditions, known CVD or advanced microvascular complications, hypoglycemia unawareness, and individual patient considerations. Postprandial glucose may be targeted if A1C goals are not met despite reaching preprandial glucose goals. Postprandial glucose measurements should be made 1 2 h after the beginning of the meal, generally peak levels in patients with diabetes. 34

35 HbA1c: the blood test with a memory What is HbA1c? Hemoglobin is a protein that makes your red blood cells red-colored. When hemoglobin picks up glucose from your bloodstream, the hemoglobin becomes glycosylated.. Glycosylated hemoglobin is HbA1c. The HbA1c test measures the percentage of HbA1c in your blood a number that corresponds to your average blood glucose for the previous 3 months.

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37 A1c measurement

38 Depicted are patient and disease factors used to determine optimal A1C targets by American Diabetes Association American Diabetes Association Diabetes Care 2016;39:S39-S46

39 Celiac screening panel (If not previously diagnosed with celiac disease) TSH with reflex FT4, anti-thyroid antibodies (If not previously diagnosed with hypothyroidism) Fasting lipid profile Albumin/Creatinine ratio and GFR (annually) Referral to ophthalmology (if not exam for > 1 year) CMP, magnesium, phosphorus CBC U/A + drug screen Lab tests Standards of medical care in Diabetes

40 ED treatment Multi - disciplinary team CBT cognitive behavioral therapy Develop healthier means of coping with negative emotion Decrease perfectionism or black/white thinking Establish regular, flexible eating patterns, and eliminating dieting and food restriction. (3 meals, 3 snacks to not trigger binge and establish routine) Murphy,R., Straebler, S., Cooper, Z., and Fairburn, C., Psychiatr Clin North Am. Sep; 33(3): Cognitive Behavioral Therapy for Eating Disorders 40

41 Treatment Challenges Diabetes complications may initially worsen Retinopathy and neuropathy often worsen Set higher blood glucose targets Continue treatment by appropriate specialist 41

42 Treatment Challenges Edema Start slowly with increasing doses of insulin Acknowledge and challenge the thought of feeling fat Keep stressing that edema will improve with consistent diabetes care Encourage activity as tolerated GI problems (e.g. gastroparesis, celiac disease) Test for celiac disease Be aware that gastroparesis with DMT1 may be long term (may effect blood sugars and insulin effectiveness and fullness)

43 Chronic Challenges Thinking insulin & food = fat Educate why the body needs insulin and that insulin is NOT the enemy Focus on numbers Acknowledge that always having to look at numbers is difficult Emphasize that numbers are data, not judgments Critchley, S., Meier, M., Taylor, D., Eating disorders and type 1 diabetes practical approaches to treatment. Practical Diabetology, March/April 2014

44 Chronic Challenges Hyperglycemia (from withholding insulin or overeating) Reduce blood sugars slowly Higher blood sugar targets, initially Reinforce ketone testing and treatment

45 Chronic Challenges Hypoglycemia (fear of, struggle to treat with food) Review background for excessive insulin Use glucose tabs for low blood glucose and to keep separate from meal plan Binge eating triggered by excessive insulin Review the option of reducing insulin or look at distribution (e.g. is insulin close to 50/50 long acting vs. short acting)

46 Therapeutic Challenges Myths and beliefs about diabetes care Keep dispelling myths and old beliefs with facts and current diabetes education Fresh start Recovery time; burnout of providers Treatment of ED-DMT1 should be a team approach, not alone.

47 Case Presentation #1 Jane is a 13 year old female Diagnosed with DMT1 for one year. Received attention after loosing wt and was diagnosed with diabetes. Started to send inappropriate selfies to friends. Long acting and rapid acting insulin pens (she has an insulin pump and CGM at home she has never used) Manipulated insulin by bending needles. Added a drop of insulin to blood to lower blood sugar readings. 47

48 Case Presentation#1 Admit weight 132 BMI 20.7 A1c 15% U/A : glucose 3+, ketones 2+ CMP WLN except glucose 316 Mag 1.7 Vital signs WNL Thyroid labs WNL Urine A/C ratio WNL Celiac panel WNL 48

49 Case Presentation #1 49

50 Case Presentation #1 50

51 Case Presentation #1 Glucose control improved over her short course of treatment. Variation in glucose when she had family style meals where she self plated or chose extras/challenges and did not dose insulin for these. Started monitoring glucose with CGM weight gain 5 lbs A1c 12.5% at discharge (5 weeks) Diabetes Education 51

52 Case Presentation #2 Julie is a 34 yo female diagnosed with Type 1 Diabetes at age 21. ED started about 2 years after diabetes dx when she stopped taking insulin to be skinny Weight lbs. Uses mainly long acting insulin I eat whatever I want and I don t gain weight without the insulin 15+ Hospitalizations for DKA (most recent was 3 days before admission) 52

53 Case Presentation #2 On Admission: Weight 101 lbs. BMI 17 Vital signs: BP 122/78, HR 110, RR 14 Diabetes specific labs: A1c >14% Glucose 767 mg/dl Urine ketones 3+, glucose 3+ Thyroid studies WNL Urine A/C ratio: <14.7 Celiac panel WNL (Ttg 5) 53

54 Case Presentation #2 Other LABS: Na 129 K+ 5.4 Co2 17 Anion Gap 17 Vitamin D 28 54

55 Case Presentation #2 Medications on admission: Insulin Glargine 18 units, Aspart unknown doses Duloxitine 60 mg BID Diabetic neuropathy Trazodone 100mg q hs Oral contraceptive daily Fluconazole 500mg weekly Increased rates of candida related to elevated blood sugars. 55

56 Case Presentation #2 LONG TERM COMPLICATIONS Neuropathy: pain improved Pregabalin 100mg 3 x daily Duloxitine 60mg BID Capsaicin cream as needed Retinopathy: Ophthalmology consult very mild diabetic retinopathy both eyes Diabetic Kidney Disease: Albumin/Creatinine Ratio <

57 Case Presentation #2 Additional challenges: Chronic illness burden Socioeconomic challenges 57

58 Case Presentation #2 Initial Labs (CMP, mag, phosphorus repeated daily x 5 days) Course of treatment A1c improved monthly >14% 9.4% 7.6% 7.3% 6.6%(most recent) Weight gain stable lbs BMI 21. Minimal edema (short coarse of spironolactone) ED thoughts reduced from 90% to 20% 58

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60 Questions??? 60