eating disorders and type 1 diabetes mellitus
DESCRIPTION
Dr Jaco Serfontein (Consultant Psychiatrists, Adult Inpatient EDS, Addenbrook’s hospital) about management of Type 1 Diabetes Mellitus in Eating Disorders, describing it as one of the most challenging clinical presentation with lack of evidence base management strategies due to paucity of research in this area.TRANSCRIPT
Eating Disorders and Type 1 DM
Jaco SerfonteinConsultant Psychiatrist
Adult Inpatient Eating Disorder Service,Addenbrooke’s Hospital, Cambridge
AndNorfolk Community Eating Disorder Service,
Norwich
Diabetes mellitus
• Diabetes = “siphon” or “running through”– Large urine volume
• Mellitus = from honey– Glucose in urine
• Uniformly fatal within weeks to months
Patient J.L., December 15, 1922 February 15, 1923
The Miracle of Insulin
Insulin
• First peptide drug• First protein sequenced• First protein structure solved• First hormone measured in blood (RIA)• First hormone gene cloned (at UCSF)• First recombinant and first biotech drug
Insulin Nobel PrizesYear Category Recipient Contribution
1923 Medicine F.G. Banting andJ.J.R. Macleod
Discovery of insulin
1947 Medicine C.F. Cori and G.T.Cori
Discovery of the course of the catalyticconversion of glycogen
1947 Medicine B.A. Houssay Discovery of the role of hormones releasedby the anterior pituitarylobe in the metabolism of sugar
1958 Chemistry F. Sanger Work on the structure of proteins, especiallyinsulin
1971 Medicine E.W. Sutherland Discoveries concerning the mechanisms ofaction of hormones
1977 Medicine R. Yalow Development of radioimmunoassays forpeptide hormones
1992 Medicine E.H. Fischer and E.G.Krebs
Discoveries concerning reversible proteinphosphorylation as a biologicregulatory mechanism
Insulin Stimulates Cellular Glucose Uptake
LiverSkeletal Muscle
Adipocytes
Intestine & Pancreas
InsulinInsulin
Insulin
Type 1 vs. type 2 diabetesLambert P, et al. Medicine 2006; 34(2): 47-51
Nolan JJ. Medicine 2006; 34(2): 52-56
Features of type 2 diabetes• Usually presents in over-30s (but
also seen increasingly in youngerpeople)
• Associated with overweight/obesity• Onset is gradual and diagnosis often
missed (up to 50% of cases)• Not associated with ketoacidosis,
though ketosis can occur• Immune markers in only 10%• Family history is often positive with
almost 100% concordance inidentical twins
Features of type 1 diabetes• Onset in
childhood/adolescence• Lean body habitus• Acute onset of symptoms• Ketosis-prone• Auto-immune illness• Used to be a fatal disease
HBA1C
• Glycosylated haemoglobin• Red blood cells live for 8 to 12 weeks• Gives an indication of glucose control over the
last 8 to 12 weeks• Well-controlled < 7%
Symptoms
• Diabetic Ketoacidosis (DKA)• Polyuria, polydipsia, polyphagia• Weight loss• Fatigue• Infection• Blurred vision
Diabetic ketoacidosis
• ↓ Insulin - ↑ glucagon, glucose released fromliver
• Polyuria - ↓K,Na – polydipsia, thirst• Free fatty acids released and converted to
ketones - ↓pH – hyperventilation• Cerebral oedema
Visual impairment:diabetic retinopathy,
cataract and glaucoma
Kidney disease(diabetic nephropathy)
Sexual dysfunction
Sensory impairment(peripheral neuropathy)
Ulceration
Stroke(cerebrovascular disease)
Heart disease(cardiovascular disease)Bacterial and fungalinfections of the skin
Severe hardening ofthe arteries (atherosclerosis) Autonomic neuropathy
(including slow emptyingof the stomach and diarrhea)
Necrobiosis lipidoica
Gangrene
The major diabetic complications
Poor blood supply to lower limbs(peripheral vascular disease)
Goals of management• Manage symptoms• Prevent acute and late complications• Improve quality of life• Avoid premature diabetes-associated death• An individualised approach
Management
Glycaemiccontrol
BPLipids
Patienteducation
Lifestyle (e.g.diet & exercise)
Foot careEye careMicroalbuminuria
& kidneys
Approximate pharmacokineticprofiles of human insulin and insulin
analoguesHirsch IB. N Engl J Med 2005; 352: 174-83
Which insulin regimens are used?
• Regimen individualised depending on various factors e.g.patient choice and cognitive abilities, age, mealtimes, diet,exercise, shiftwork, target HbA1C, risk or experience ofhypoglycaemia, previous control if already on insulin.
Three basic regimens NICE. Type 1 diabetes Clinical Guideline 15, 2004
• One, two or three insulin injections/day• Multiple daily injection• Continuous subcutaneous insulin infusion
OR
DAFNE
• Dose Adjustment For Normal Eating• Structured 5 day course• Delivered in group format• Estimating carbohydrate content in meals and
adjusting insulin dose accordingly• Living as normal a life as possible
Prevalence
• AN – 0.3%• BN – 1%• ED-NOS – 2%• T1DM – 2.4X increased rates of ED• 25% of females with T1DM develop clinically
important disturbances of eating habits andattitudes in their lives
Medical Risks
• Insulin purging women>>men• Comorbid DM + ED – ↑risk of DM
complica ons, ↑risk of ED complica ons• DM mortality 2.2 per 1000 persons per year• DM + AN mortality 34.6 per 1000 persons per
year (Nielsen et al., 2002)
• Mean age of death 45y (58y T1DM) (Goebel-Fabbri,2008)
• Increased psychiatric comorbidity
• To explore the thoughts, feelings and experiencesof patients with type 1 diabetes and EatingDisorders or disordered eating/weight concernsin order to inform the development of:– effective strategies to prevent the development of
eating disorders in patients with type 1 diabetes– early identification of patients at risk of and with
emerging eating disorders/disordered eating.– appropriate treatment approaches for patients with
established co-morbid Type 1 Diabetes and eatingdisorders
Rigidity
Perfectionism
Family difficulties
Weight loss
Diagnosis of DM
Weight gain
Focus on importanceof weight, food,healthy living
Body dissatisfaction
Impact ofdiagnosis
Loss of control
Low mood
Fear ofhypoglycaemia/injecting
GuiltExcessiverestriction
Binge eating
Purging/insulinomission
Poorglycaemiccontrol
Anorexia nervosa Bulimia nervosa BED
Perfectionism surroundingsugars and excessivetesting
↑HbA1c Considerable weight gain
Recurrent hypoglycaemiarequiring third-partyassistance
Recurrent hospitalisations/DKA
High insulin requirements
Unusual patterns ofexercise
Reluctance to inject I frontof others
High levels ofdistress/depressionsurrounding food intake
Insulin omission to preventhunger
Concurrentpsychopathology
Low mood
Possible medical concernsregarding purging
Treasure and Ridge, 2012
‘A’ ‘B’ ‘C’
AN 0 1 49
BN 1 7 9
BED 2 5 2
EDNOS 0 0 1
NICE (2004)• 1.1.6.3 Young people with type 1
diabetes and poor treatmentadherence should be screened andassessed for the presence of an eatingdisorder.
• 1.1.4.2 Treatment of both subthresholdand clinical cases of an eating disorderin people with diabetes is essentialbecause of the greatly increasedphysical risk in this group.
• 1.1.4.3 People with type 1 diabetes andan eating disorder should haveintensive regular physical monitoringbecause they are at high risk ofretinopathy and other complications.
Screening – The SCOFF questionnaire
• 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 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?
• 2 or more out of 5 predicts an ED with 100% sensitivity and 87.5%specificity Morgan et al (1999)
• Do you sometimes take less insulin than you should to manage yourweight?
Screening
• Diabetes Eating Problem Survey (DEPS-R)– Self-report, <10 min, Cronbach’s α = 0.86 (Markowitz et
al, 2010)
Treatment• Might be pre-contemplative• ED egosyntotic• Motivational interviewing• Avoid setting difficult/unattainable goals• Focusing excessively on glycaemic control may be
counterproductive, be flexible• Do not prescribe a strict or rigid meal plan• Initial focus could be as small as completing basal
insulin doses to prevent DKA (Goebbel-Fabbri, 2009)• Relax the rules around blood glucose targets
temporarily – patient safety is the main goal
Treatment
• Psychoeduction – mixed results, someimprovement in ED pathology, but does notimprove metabolic control, treatmentadherence or decrease the frequency ofinsulin omission.
• Motivational Interviewing strategies• Individual or Group therapy (CBT)• Inpatient treatment
The Role of the Family
• Treatment mostly onoutpatient basis
• Families should not be seenas problem, but as part ofthe solution
• Family therapy inadolescents
• Maudsley model ofcollaborative care
In summary
• Weak evidence base• Complex, high risk, difficult to treat patients• Requiring joint working and direct
communication between different disciplines