1. Eating Disorders inEating Disorders in
Type 1 DiabeticsType 1 Diabetics
Deborah Green
University of Bristol

2. ObjectivesObjectives
 Type 1 Diabetes
 Pathophysiology
 Insulin functions
 Eating disorders in diabetics - ‘Diabulimia’
 Definition and development
 Signs and symptoms
 Patient views
 Management options - Evidence based medicine
 Miss E’s story

3. Type 1 DiabetesType 1 Diabetes
• B cell destruction
within the Islet cells
leading to absolute
insulin deficiency
• 90% of new diagnosis’
occur under the age of
30 years
(Image 1)

4. Insulin TherapyInsulin Therapy
 Insulin replacement remains the
mainstay of treatment for type 1
diabetes

5. Converts glucose to glycogen to be
stored in the liver
Enables glucose to be transported
into cells from blood
Increases glucose utilisation
(glycolysis)
Vs

6. ‘‘Diabulimia’Diabulimia’
 Not officially recognised as an eating disorder
Omission of insulin
Glucose continues to circulate in the blood and
is excreted in the urine
Body forced to obtain energy from fat and
muscle stores RAPID WEIGHT LOSS

7. Eating DisordersEating Disorders
‘Diabulimia’ – Omission of
insulin by type 1 diabetics to
prevent weight gain.

8. PrevalencePrevalence
 Eating disorders that meet DSM-IV criteria,
particularly bulimia nervosa and binge eating
disorder, are more than twice as common
in adolescent girls with Type 1 Diabetes than in
their non-diabetic peers
(Nissim R et al, 2002)
 Study of adolescent diabetics: 70% of girls
with poor glycemic control omitted their
insulin to compensate for over eating
(Greca et al, 2004)

9. Standard diabetes treatment goals:
• Good glycemic control
• Attention to CHO counting
Encourages
perfectionism for
optimal control and
weight
Weight gain
associated with
intensive insulin
therapy
Feeling deprived of
food choices. Binge
eating develops
Depressive symptoms,
poor motivation for self
care
Negative feelings
about shape and
fear of weight gain

10. What to look out forWhat to look out for
Physical Psychological
• Consistent hyperglycaemia
and high HbA1C
• Irregular eating patterns
(similar to BN)
• Extreme fatigue and weight
loss
• Denial
• Thirst and polyuria • Distorted perception of
body image
• Frequent DKA • Change in personality or
mood swings

11. Long Term ComplicationsLong Term Complications
Retinopathy
Neuropathy

12. What the patients say...What the patients say...
‘A small amount of milk and water
on the test strip gives a normal
reading. If mum gets suspicious I
add fruit juice to make the reading
higher...’
‘...I would rather be thin with
kidney failure and retinopathy
than fat and healthy...’
‘I need to lose 15 pounds in 2 weeks
to fit into my prom dress. I know I
can do this if I skip my insulin...’

13. Evidence Based MedicineEvidence Based Medicine
Literature Search
•Cochrane Database
•Prodigy – NHS clinical knowledge summaries
•NICE Guidance - Eating Disorders
•Journal Articles (www.library.nhs.uk)
•Goebel-Fabbri A. (2009) Disturbed eating behaviours
and eating disorders in type 1 diabetes: Treatment
recommendations

14. Evidence Based MedicineEvidence Based Medicine
1. NICE Guidance - Eating Disorders
(with concurrent physical conditions)
 Screening for eating disturbances in
patients who are not compliant
 Close collaboration between
psychiatric and diabetes teams

15. Evidence Based MedicineEvidence Based Medicine
1. NICE recommendations
•Psycho-education
GOAL – to understand and manage psychiatric illness
in association with physical illness
RCT (n=212) showed improvement in eating
disturbance but not glycemic control with psycho-
education vs standard CBT therapy
(Olmsted et al, 2002)
Limitations – recommendations grouped with BN

16. Evidence Based MedicineEvidence Based Medicine
2. Goebel-Fabbri A. (2009) Disturbed eating
behaviours and eating disorders in type 1
diabetes: Treatment recommendations
Family co-management
Small, achievable goals
◦ Avoiding DKA’s
◦ Regular meal patterns
◦ Flexible, non-restrictive diet
Limitations – Recommendations based on
professional experience.
No formal outcome studies to date

17. Clinical Case – Miss EClinical Case – Miss E
•Type 1 diabetic omitting insulin
• Diagnosed aged 2 years
• Parents very controlling over her diabetes
• Felt individualised at school
• Resented being different
• Admission to the Priory Hospital
• 73% of ideal body weight – BMI = 14
• Taking small amounts of basal insulin only
• Food consumption very traumatic

18. The MDT ApproachThe MDT Approach
Dietician
• Aim for 3 meals daily – initially 300kcal/day in food
• Weight gain achieved with FORTISIPS
• Supervised table at meal times
Therapies (psychologist, therapies team)
• Integrational activities – eating out, cooking, food shopping
• Art and drama therapy – positive attitude to life
• Psycho-education – family involvement

19. The MDT ApproachThe MDT Approach
Diabetes Nurses
• Matching fast-acting insulin dose to CHO portion sizes
• Recognition of symptoms of hypoglycaemia and long term
complications

20. ReflectionReflection
 Awareness of insulin omission as an inappropriate
compensatory behaviour leading to eating
disturbances and disorders
 Early recognition in diabetic clinics
 Multidisciplinary team involvement in treatment
 Patient and family centred care – empowering
people to take control of their own conditions

21. Personal Learning OutcomesPersonal Learning Outcomes
 Obtaining an understanding of the
patient’s real concerns and worries
 Not allowing personal attitudes towards
an illness get in the way of your approach
to treatment
 ‘If you are patient, you will get
there in the end’ (Miss E, 2010)

22. ReferencesReferences1. Taki M et al. (1999) Differences between bulimia nervosa and binge eating disorder in
females with type 1 diabetes: the important role of insulin omission. J of Psychosom
Res. 47(3) 221-31
2. Taki et al. (2002) Classification of type 1 diabetic females with bulimia nervosa into
subgroups according to purging behaviour. Diabetes Care. 25(9): 1571-5
3. Nissim R et al. (2002) Eating disturbances in adolescent girls with type 1 diabetes
mellitus. J of Psychosom Res. 141(10): 902-7
4. Olmsted M et al. (2002) The effects of psychoeducation on disturbed eating attitudes
and behaviour in young women with type 1 diabetes mellitus. Int J of Eating Disorders.
32(2): 230-39
5. Scott J et al. (1998) Eating disorders and insulin dependent diabetes mellitus.
Psychosomatics. 39: 233-43
6. Goebel-Fabbri A.E. (2009) Disturbed eating behaviours and eating disorders in type 1
diabetes: clinical significance and treatment recommendations. Current Diabetes
Reports. 9: 133-9
7. Taylor D, Paton C, Kerwin R. (2008) The Maudsley Prescribing Guidelines 9th
Edition.
Informa Healthcare. Eating disorders P433-6
8. NICE Guidance – Eating disorders: Core interventions in the treatment and management of
anorexia nervosa, bulimia nervosa and related eating disorders. 2004.
9. www.diabetes.org.uk
10. www.diabeteshealth.com
11. www.timesonline.co.uk
12. CAMS, The Delancy Hospital, Cheltenham
13. The Priory Hospital, Bristol