Eating Disorders and Type 1 Diabetes Mellitus
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Eating Disorders and Type 1 Diabetes Mellitus

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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 ...

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.

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Eating Disorders and Type 1 Diabetes Mellitus Presentation Transcript

  • 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) DN: cn=Yasir Hameed (MRCPsych) gn=Yasir Hameed (MRCPsych) c=United Kingdom l=GB o=Norfolk and Suffolk NHS Trust e=yasirmhm@yahoo.com Reason: I am the author of this document Location: 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
  • 7. 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
  • 8. 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%
  • 9. Symptoms • Diabetic Ketoacidosis (DKA) • Polyuria, polydipsia, polyphagia • Weight loss • Fatigue • Infection • Blurred vision
  • 10. 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
  • 11. 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)
  • 12. 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
  • 13. Approximate pharmacokinetic profiles of human insulin and insulin analogues Hirsch IB. N Engl J Med 2005; 352: 174-83
  • 14. 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
  • 15. 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
  • 16. 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
  • 17. 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
  • 18. • 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
  • 19. 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
  • 20. 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
  • 21. ‘A’ ‘B’ ‘C’ AN 0 1 49 BN 1 7 9 BED 2 5 2 EDNOS 0 0 1
  • 22. 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.
  • 23. 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?
  • 24. Screening • Diabetes Eating Problem Survey (DEPS-R) – Self-report, <10 min, Cronbach’s α = 0.86 (Markowitz et al, 2010)
  • 25. 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
  • 26. 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
  • 27. 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
  • 28. In summary • Weak evidence base • Complex, high risk, difficult to treat patients • Requiring joint working and direct communication between different disciplines