2/11/217 Type 1 Diabetes and Eating Disorders Marietta Stadler In type 1 diabetes (T1DM) eating disorders (ED) are a common complex problem 4, adults in the UK with T1DM 3% of women 1,2 and 7% of men 3 with T1DM restrict insulin to control weight Ketoacidosis & severe hypoglycaemia rates increased 5 Blogger with Diabulimia No effective intervention ED is twice as common in people with T1DM than in those without 4 1 Accelerated late complications 1 3-fold higher mortality than T1DM without ED 1 Goebel-Fabri et al, Diabetes Care 28; 2 Polonsky WH et al, Diabetes Care 1994; 3 Bachle C et al, Plos One 215; JM et al, BMJ 2; 5 Scheuing N et al, Diabetes Care 214 4 Jones 1
2/11/217 DIABULIMIA Diabulimia Only possible in T1DM Fear of weight gain Deliberate omission/ restricdon of insulin to control weight Can have normal body weight and look healthy Red flags: high HbA1c, recurrent admissions for DKA 2
Type 1 diabetes basics Type 1 diabetes refresher of basic facts Auto- immune mediated destruction of insulin producing beta- cells in pancreatic islets Difference to type 2 diabetes is absolute insulin deficiency Diagnosis under the age of 3 years in most cases Currently, T1DM can neither be prevented nor stopped (not related to lifestyle) 3
Life expectancy pre-, post insulin era Dublin JI, Diabetes 1952; Life expectancy by age of diagnosis Type 1 diabetes refresher of basic facts Only treatment is replacing insulin in the most physiological way possible. Insulin is needed for life- and life long. Glucotoxicity causes micro (eye, kidney)- and macrovascular (heart, brain, leg) late complications. Acute complications caused by lack of insulin- diabetes ketoacidosis too much insulin- severe hypoglycaemia 4
HbA1c and mortality risk Vienna Lainz Cohort: enrolment 1983, mean diabetes duracon at baseline 15yrs 3 yrs observadon, quardles baseline HbA1c (n=641) The lower the befer???? HbA1c- quartiles: Q 1: 6.5% Q 2: 6.6-7.4% Q 3: 7.5-8.4% Q 4: 8.5-14.8%` Log rank test p<.4 Stadler M et al JCEM 214 Benefits and risks in the DCCT 16 1 Hypoglycaemia Retinopathy Retinopathy per 1 patient years 14 12 1 8 6 4 2 Severe hypoglycaemia per 1 patient years 8 6 4 2 5 6 7 8 9 1 11 12 13 14 DCCT Group, Diabetes 1996 Haemoglobin A 1c 5
Gold-Standard: Basis-bolus insulin replacement with dose adjustment Dose Adjustment For Normal Eating h^p://www.dafne.uk.com/ h^p://www.carbsandcals.com/ or similar structured educadon programmes Principles: Separation of basal insulin from meal insulin requirements Patients taught to count carbohydrates Units / 1g carbohydrate Individualised to patients Individualised to meals Corrective doses- Insulin sensitivity factor Adjustments for exercise and alcohol Standardized mortality racos, populacon based registries incidence registries and cross secconal cohorts 16 14 12 1 8 6 4 2 male female Harjutsalo V et al. BMJ 211 Feltbower RG et al Diabetes Care 28 Pa^erson CC et al. Diabetologia 27 Skivarhaug T et al Diabetologia 26 Health and Social Care InformaDon Centre, Dahlquist G et al Diabetes Care 25 UK 213 Harding J et al Diabetes Care 214 Secrest A et al Diabetes 21 Morimoto A et al Diabetologia 213 6
Main causes of death (%)/ Top 3 populadon based registries, reviewed clinically 35 3 25 2 15 1 5 Acute ComplicaCons CVD Renal Mental health Sudden death/dead in bed Accident Secrest A et al Diabetes 21 Morimoto A et al Diabetologia 213 Feltbower RG et al Diabetes Care 28 Skivarhaug T et al Diabetologia 26 Dahlquist G et al Diabetes Care 25 3 DKA and hypoglycaemia cause of death % 25 % 2 15 1 DKA Hypoglycaemia dead in bed/ sudden death 5 EURODIAB Yorkshire Norway Sweden Pa^erson CC et al Diabetologia 27 Feltbower RG et al Diabetes Care 28 Skivarhaug T et al Diabetologia 26 Dahlquist G et al Diabetes Care 25 7
Living with type 1 diabetes Typ 1 Diabetes the balancing act principles of insulin replacement family, work, friends, hobbies Illness Food Insulin Diabetes-therapy Exercise Ketoacidosis Unconscious hypo Car crash Late complicadons 8
Insulin effects/dka muscle Protein synthesis build glykogen protein degradation Glykogen degradation Insulin Pancreas Fat tissue: Lipogenese Lipolyse Glucose uptake Free Fatty Acids Ketone bodies Glucose Liver: Glykogen degradation Gluconeogenesis Ketone bodies ph Osmolalility Adapted from Wolfsdorf J, Diabetes Care 26 Silbernagel Taschenatlas Pathophysiologie Insulin secretion physiology Serum insulin (mu/l) 5 4 3 2 1 Bolus insulin needs Meal Meal Meal Basal Insulin Needs 2 4 6 8 1 12 Approx. daily insulin needs: 4 5 E Time 14 (Hours) 16 18 2 22 24 ~5 % : prandial= ~1 Unit/ 1 g Carb ~5 % : basal = fasting = 1 Unit /h 9
Insulin Time Action Curves Relative Insulin Effect Rapid (Novorapid, Humalog, Apidra ) Short (Regular) = Actrapid Intermediate (NPH)= Humulin I, Insulatard Long (Glargine)=Lantus (Detemir)= Levemir 2 4 6 8 1 12 14 16 Time (Hours) 18 2 Basal Bolus insulin replacement 2x daily NPH, or Detemir/ or 1x Glargin AND 3x daily fast acting for main meals Bolus: ½ of total daily insulin divided for 3 meals Fast acting 8 6 1 Basal: ½ of total daily insulin divided up BD NPH 12 12 prescription of fixed meals with fixed amounts of carbs 5 4 3 2 1 2 4 6 8 1 12 14 16 18 2 22 24 1
Insulin pump therapy CSII= continuous subcutaneous insulin infusion basal rate = CSII of short acting insulin for basal insulin supply replacing basal insulin (long acting insulin) IU/h 2 1 bolus temporary changes of BR decrease/sport increase/ illness, pregnancy basal rate ı ı ı ı ı. 6. 12. 18. 24. bolus for meals and correction bolus calculator as support How much insulin would you give for this breakfast? Croissant 5g, 25 kcal, 2g Jam 2g, 5 kcal, 1g Joghurt 15g, 2 kcal, 15 g 1 Unit Insulin per 1g Carbs -> 4.5 Units 11
How much insulin would you give for this breakfast? This was easy? 1 Unit Insulin per 1g Carbs -> 4.5 Units Insulin pen in 1 Unit steps- round up or down? Cycling to the train station- give less insulin, or eat extra? Just came down with a cold and glucose running high? Had a bad hypo yesterday at that time, now very anxious to inject? Put on a little bit of weight recently, inject less and run it off? Why do people with T1DM have a higher risk for eadng disorders? 12
T1DM and eating disordersan unhealthy relationship Diabetes management per se Multiple daily insulin injections, carbohydrate counting very structured and unhelpful focus on food and body weight Interferes with perfectionist coping style (difficult to get T1DM treatment right - source for frustration!) Blood sugar fluctuations in T1DM? neuroadaptive changes, pre-disposing to addictive pattern of loss of control over eating T1DM and eating disordersan unhealthy relationship chronic condition Needing insulin for life, holiday from T1DM management not possible diabetes burn-out Age of diabetes onset is often teenage- Teenage years: increased insulin resistance (hormonal changes), prone to gain weight co-morbid depression Family characteristics and dynamics Transition from T1DM managed by family/carers to self management- T1DM therapy dominant topic around mealtimes 13
T1DM and eating disordersan unhealthy relationship Young women with diabetes have more than double the risk of developing an eating disorder than women without diabetes. 31% of women with diabetes reported intentionally restricting their insulin doses; the rates of restriction peaked in late adolescence and early adulthood. 2 Insulin-omission purging: loss of glucose through urine, weight loss through katabolic state of DKA 2 Polonsky WH, et aldiabetes Care 1994 3 Rydall AC, et al.n Engl J Med 1997 4 Peveler RC, et al. Diabetes Care 25 5 Goebel-Fabbri AE, et al. Diabetes Care 27 T1DM and eating disordersan unhealthy relationship Higher HbA1c, higher late complication rates 1 Higher DKA admission rates 2 T1DM plus ED: 3x higher mortality rates 3 in comparison with T1DM 1 Rydall AC, et al.n Engl J Med 1997 2 Peveler RC, et al. Diabetes Care 25 3 Goebel-Fabbri AE, et al. Diabetes Care 27 14
T1DM and eating disordersan unhealthy relationship Goebel-Fabri A et al 28 Developing a theoretical maintenance model for disordered eating in Type 1 diabetes" DiabeCc Medicine Volume 32, Issue 12, pages 1541-1545, 16 JUL 215 DOI: 1.1111/dme.12839 h^p://onlinelibrary.wiley.com/doi/1.1111/dme.12839/full#dme12839-fig-1 15