reprinted courtesy eating disorders review
Managing an eating disorder and type 1 diabetes mellitus (T1DM) is extremely challenging for clinicians and patients alike, Jennifer L. Gaudiani, MD, Founder and Medical Director of the Gaudiani Clinic, Denver, told the audience in her session, “Eating Disorders in Type 1 Diabetes.”
Puberty is the peak time for diagnosing both T1DM and eating disorders, Dr. Gaudiani said, noting that eating disorders or disordered eating affects as many as 30% of patients with T1DM. A major psychological risk factor is that while T1DM presents with initial weight loss, once blood glucose is regulated and weight is restored, the young patient may believe that “insulin makes me fat.” This can lead the patient to withhold or restrict her insulin to lose weight (diabulimia). Furthermore, Dr. Gaudiani said, the presence of both disorders causes a surge in mortality in these patients. For example, in a 10-year follow-up study (Nelsen et al, 2002), the death rate for those with AN alone was 2%, and for those with T1DM alone was 6.5%, but for those with AN and T1DM, the mortality rate rose to 38%. Concurrent diagnoses of an ED and T1DM confer a 5 times greater mortality rate than AN alone, Dr. Gaudiani added. In another 11-year study, she noted that patients with EDs and T1DM were 3.2 times more likely to die, and their lifespan was cut by 13 years, compared to patients who did not restrict insulin. In addition, comorbidities such as anxiety and personality and behavioral disorders abound in those with concurrent diagnoses of T1DM and eating disorders, she said.
Physical side effects
Edema and the fear of developing it is one of the greatest barriers to recovery and to patients resuming their insulin, Dr. Gaudiani added. Secondary aldosteronism is at work, and insulin itself causes resorption of water and salt in the renal tubule, causing refeeding edema. Clinicians can minimize this by using spironolactone, and making sure patients are forewarned about the signs of diabetic ketoacidosis, she said. The spectrum of new or worsening complications can include retinopathy, gastroparesis, neuropathy and/or neuritis, and vasovagal syncope. An additional problem occurs when hypoglycemia triggers binge eating.
A multidisciplinary team is needed.
Inpatient or residential treatment demands the help of a multidisciplinary team, including therapist, endocrinologist, dietitian/CDE a nurse, psychiatrist, and other medical specialists, as the patient progresses from full support to autonomy.
At first the staff monitors glucose and insulin, and then care is agreed upon by the staff and patient. A RN and the patient agree on the insulin dosage, and the patient then draws and administers her insulin under supervision. In time, patients can then gradually assume full responsibility for diabetes self-care. Dr. Gaudiani noted that team members should have experience with, or at least be knowledgeable about,T1DM and EDs. She added that the key to successful treatment is coordination of the treatment plan and communication about progress. Insulin dosage must be adjusted frequently, collaboratively, and incrementally, both up and down, she said. For outpatient care, patients must be willing to take their insulin to avoid diabetic ketoacidosis. As in inpatient care, outpatient care includes participation by numerous professionals, including school health personnel.
Should patients use an insulin pump? Dr. Gaudiani pointed out that studies have shown that insulin pump therapy achieved significantly lower glycated hemoglobin (A1c) levels with “fewer hypos and no weight gain”; it is also used successfully in TIDM patients with mental disorders. The pros include need for only one “stick” every 3 days; dosing is similar to using a cell phone; and there are fewer barriers to keeping insulin levels steady. The negatives about using an insulin pump therapy are that it is a “24/7 reminder of the presence of diabetes and can be a trigger in outpatient therapy if use of the pump was involved in earlier negative behaviors,” she said.