Eating disorders in diabetes: The missed opportunities
In a thought-provoking and, at times, emotionally-charged session, expert presenters critiqued the management of eating disorders in people with type 1 and type 2 diabetes, offering practical tips to reduce the impact of this often overlooked comorbidity.
Jacqueline Fosbury (Sussex Community NHS Foundation Trust, UK) opened by highlighting that one in four adults in the UK have a diagnosis of binge eating disorder (BED). Nonetheless, it has only been classified as a psychiatric disorder since 2013 under the Diagnostic and Statistical Manual of Mental Disorders.
There are several factors that may increase the risk for BED, such as family conflict, sexual abuse, and a family member with an alcohol or drug addiction. She described the condition as a “first world problem,” only occurring in affluent societies.
Clinically significant BED is strongly linked to prediabetes and diabetes, with prevalence rates of between 20.0% and 25.6% in people with type 2 diabetes, which Fosbury said created “double trouble” for healthcare practitioners treating them.
So, what can clinicians do to identify and manage BED? Screening for eating disorders should be routinely carried out in patients with diabetes; this can be performed using simple questionnaires. Currently available questionnaires, such as BEDS-7 (7-Item Binge-Eating Disorder Screener), are not yet diabetes-specific but Fosbury and her team are working with expert dieticians to develop this.
If BED is diagnosed it is important to address any underlying emotional problems. Treatment for these difficulties, however, should not necessarily supersede treatment for BED, but they can be “tackled alongside” each other, said Fosbury.
Antidepressant medications as well as psychotherapy and cognitive analytic therapy are options for managing BED and any underlying depression. “Eating disorders are about feelings,” Fosbury stressed, noting that online support groups and helplines can provide invaluable support to the patient and their families.
She pointed out that the involvement of a diabetes dietician can be resisted by patients; therefore, setting up introductory sessions with the psychotherapist and dietician can help to soften this referral.
Fosbury summarized that BED is an important consideration in the management of people with type 2 diabetes, as unmanaged eating disorders can lead to the exacerbation of diabetes complications.
Living with ‘diabulimia’
Drawing on her first-hand experience of “diabulimia,” Lynsey Choules, a patient with type 1 diabetes, gave an honest and moving insight into her journey through the healthcare system, highlighting the missed opportunities in her care that contributed to life-changing consequences. She advised the delegates to “look for the clues” and set realistic goals rather than focusing on the numbers. You can read Lynsey’s full story here.
What can clinicians do?
Speaking from the view of a pediatrician, Simon Chapman (King’s College Hospital NHS Foundation Trust, London, UK) asked a difficult question: could healthcare professionals be part of the problem?
The management of diabetes is based upon continuous weight and growth surveillance whereby the patient is rewarded for counting food. This “medicalization” of the diet from a young age can lead to negative effects in adolescence and adulthood, so clinicians need to be careful about the messages they are delivering in their clinics.
Chapman continued by listing several signs to help identify a potential eating disorder in people with diabetes, including:
- a drop in basal insulin infusion rate;
- repeated hospitalizations for poor blood sugar control;
- amenorrhea; and
Parental supervision of insulin doses and glucose monitoring can help both identify and prevent the development of an eating disorder if the above signs are detected.
Chapman closed by recommending the pediatric version of the MaRSiPAN (Management of Really Sick Patients with Anorexia Nervosa) guidelines for practical advice and offering his own recommendations for reducing the impact of an eating disorder.
- Early referral to an eating disorders team, as “early intervention prevents later severity.”
- Be upfront with the patient and focus on restorative health as opposed to their weight.
- To challenge the patient while maintaining compassion, externalization of the disorder can be a useful tool. The technique involves separating the illness from the patient, promoting the idea that the negative behavior is caused by the eating disorder and not by the patient themselves.
- Ensure close and collaborative working with the eating disorders team as they often do not have the diabetes-specific knowledge.
- Do not “leave it to the psychologist,” as the medical healthcare provider’s voice can be very powerful for not only the patient, but the parents and siblings too.
Tips from a psychological wellbeing practitioner
The last presenter moved on to psychologic techniques that all healthcare professionals can utilize to maximize patient engagement in their diabetes care. Abeni Lüken (Sussex Community NHS Foundation Trust, Brighton, UK) offered advice on methods in information gathering, shared decision-making, and behavior change in diabetes self-care.
She began by reiterating the basics of written, verbal, and body language to demonstrate empathy, citing the UK National Health Service Language Matters report as a useful tool in guiding this.
Lüken said that coaxing information from a patient with an eating disorder can be difficult as they often display anxious and deflective behavior. She outlined the “funneling technique,” which can help structure the conversation by opening up the dialogue before filtering down to the detail using closed questions and shared problem statements. Stating the length of the appointment at the beginning can also help to focus the session.
Changing behavior is a “multicomplex [and] multistage process,” remarked Lüken. To facilitate this process, both the pros and cons of this change should be given to the patient so that a shared decision can be made.
To solidify the patient’s commitment to this change, it is also important to set goals. Lüken recommended starting by asking the patient what they would like to change and what was most important to them. Beginning with the most achievable goal can help build motivation, and using “SMART” goals can help structure the longer-term plan.
Lüken’s take-home tips for the delegates were:
- Always set collaborative agendas and goals.
- Funnel down to the main problem and reframe it in a positive light.
- Keep to time boundaries.
- Consider that the patient may feel frightened about taking insulin.
- Expect the patient wants to change at their own pace, not ours.
By Rebecca Cox
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