This document discusses eating disorders and type 1 diabetes. It notes that about 25% of females with type 1 diabetes will develop clinically significant eating disturbances. Having both an eating disorder and diabetes significantly increases medical risks and can lead to life-threatening complications. Effective treatment requires screening for eating disorders, managing both medical and psychological aspects, focusing on patient safety over glycemic control targets, and potentially involving family support.

1. Eating Disorders and Type 1 DM
Jaco Serfontein
Consultant Psychiatrist
Adult Inpatient Eating Disorder Service,
Addenbrooke’s Hospital, Cambridge
And
Norfolk Community Eating Disorder Service,
Norwich
Yasir
Hameed
(MRCPsy
ch)
Digitally signed by Yasir
Hameed (MRCPsych)
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Suffolk NHS Trust
e=yasirmhm@yahoo.com
Reason: I am the author of this
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Date: 2014-06-26 21:45+01:00

2. Diabetes mellitus
• Diabetes = “siphon” or “running through”
– Large urine volume
• Mellitus = from honey
– Glucose in urine
• Uniformly fatal within weeks to months

3. Patient J.L., December 15, 1922 February 15, 1923
The Miracle of Insulin

4. 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

5. Insulin Nobel Prizes
Year Category Recipient Contribution
1923 Medicine F.G. Banting and
J.J.R. Macleod
Discovery of insulin
1947 Medicine C.F. Cori and G.T.
Cori
Discovery of the course of the catalytic
conversion of glycogen
1947 Medicine B.A. Houssay Discovery of the role of hormones released
by the anterior pituitary
lobe in the metabolism of sugar
1958 Chemistry F. Sanger Work on the structure of proteins, especially
insulin
1971 Medicine E.W. Sutherland Discoveries concerning the mechanisms of
action of hormones
1977 Medicine R. Yalow Development of radioimmunoassays for
peptide hormones
1992 Medicine E.H. Fischer and E.G.
Krebs
Discoveries concerning reversible protein
phosphorylation as a biologic
regulatory mechanism

6. Insulin Stimulates Cellular Glucose Uptake
Liver
Skeletal Muscle
Adipocytes
Intestine & Pancreas
Insulin
Insulin
Insulin

8. Type 1 vs. type 2 diabetes
Lambert 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 younger
people)
• 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 in
identical 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

9. 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%

10. Symptoms
• Diabetic Ketoacidosis (DKA)
• Polyuria, polydipsia, polyphagia
• Weight loss
• Fatigue
• Infection
• Blurred vision

11. Diabetic ketoacidosis
• ↓ Insulin - ↑ glucagon, glucose released from
liver
• Polyuria - ↓K,Na – polydipsia, thirst
• Free fatty acids released and converted to
ketones - ↓pH – hyperventilation
• Cerebral oedema

12. 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 fungal
infections of the skin
Severe hardening of
the arteries (atherosclerosis) Autonomic neuropathy
(including slow emptying
of the stomach and diarrhea)
Necrobiosis lipidoica
Gangrene
The major diabetic complications
Poor blood supply to lower limbs
(peripheral vascular disease)

13. Goals of management
• Manage symptoms
• Prevent acute and late complications
• Improve quality of life
• Avoid premature diabetes-associated death
• An individualised approach
Management
Glycaemic
control
BP
Lipids
Patient
education
Lifestyle (e.g.
diet & exercise)
Foot care
Eye careMicroalbuminuria
& kidneys

14. Approximate pharmacokinetic
profiles of human insulin and insulin
analogues
Hirsch IB. N Engl J Med 2005; 352: 174-83

15. 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 of
hypoglycaemia, 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

16. 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

17. 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 and
attitudes in their lives

18. 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

19. • To explore the thoughts, feelings and experiences
of patients with type 1 diabetes and Eating
Disorders or disordered eating/weight concerns
in 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 eating
disorders

20. Rigidity
Perfectionism
Family difficulties
Weight loss
DiagnosisofDM
Weight gain
Focus on importance
of weight, food,
healthy living
Body dissatisfaction
Impact of
diagnosis
Loss of control
Low mood
Fear of
hypoglycaemia/
injecting
GuiltExcessive
restriction
Binge eating
Purging/
insulin
omission
Poor
glycaemic
control

21. Anorexia nervosa Bulimia nervosa BED
Perfectionism surrounding
sugars and excessive
testing
↑HbA1c Considerable weight gain
Recurrent hypoglycaemia
requiring third-party
assistance
Recurrent hospitalisations/
DKA
High insulin requirements
Unusual patterns of
exercise
Reluctance to inject I front
of others
High levels of
distress/depression
surrounding food intake
Insulin omission to prevent
hunger
Concurrent
psychopathology
Low mood
Possible medical concerns
regarding purging
Treasure and Ridge, 2012

22. ‘A’ ‘B’ ‘C’
AN 0 1 49
BN 1 7 9
BED 2 5 2
EDNOS 0 0 1

23. NICE (2004)
• 1.1.6.3 Young people with type 1
diabetes and poor treatment
adherence should be screened and
assessed for the presence of an eating
disorder.
• 1.1.4.2 Treatment of both subthreshold
and clinical cases of an eating disorder
in people with diabetes is essential
because of the greatly increased
physical risk in this group.
• 1.1.4.3 People with type 1 diabetes and
an eating disorder should have
intensive regular physical monitoring
because they are at high risk of
retinopathy and other complications.

24. 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 your
weight?

25. Screening
• Diabetes Eating Problem Survey (DEPS-R)
– Self-report, <10 min, Cronbach’s α = 0.86 (Markowitz et
al, 2010)

26. 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

27. Treatment
• Psychoeduction – mixed results, some
improvement in ED pathology, but does not
improve metabolic control, treatment
adherence or decrease the frequency of
insulin omission.
• Motivational Interviewing strategies
• Individual or Group therapy (CBT)
• Inpatient treatment

28. The Role of the Family
• Treatment mostly on
outpatient basis
• Families should not be seen
as problem, but as part of
the solution
• Family therapy in
adolescents
• Maudsley model of
collaborative care

29. In summary
• Weak evidence base
• Complex, high risk, difficult to treat patients
• Requiring joint working and direct
communication between different disciplines