ADVANCE for Nurses
Stuart Koman, Ph.D.
It’s well known that those who have type 1 diabetes are susceptible to medical complications such as eye disease, kidney disease and nerve damage.
It’s less well-known that they are also susceptible to eating disorders.
Studies show that a person with type 1 diabetes is more than twice as likely as the average person to develop an eating disorder.1,2
The National Institute of Mental Health estimates that 0.6% of the U.S. population suffers from anorexia, 1% from bulimia and 2.8% from binge-eating disorder.
The American Diabetes Association estimates that 25.8 million Americans have diabetes, and approximately 5% of them have type 1 diabetes.
Why the dual diagnosis of diabetes and eating disorders is so common is not known for certain, but it may be because individuals with type 1 diabetes are taught to be focused on food and managing what they eat. They may develop rigid ideas about “good food” and “bad food,” which may raise the risk for an eating disorder.
In addition to being susceptible to anorexia, bulimia and binge-eating disorder, those with type 1 diabetes often skip or reduce insulin injections, because insulin may cause weight gain – especially if it’s not precisely tailored to the body’s needs, according to an interview conducted with Ann Goebel-Fabbri, PhD, of the Joslin Diabetes Center, Boston.
Insulin restriction causes high blood glucose (hyperglycemia), which the body then attempts to regulate by excreting it through urine (glycosuria). In this way, insulin restriction functions as a powerful but dangerous calorie purge symptom of an eating disorder.
When insulin restriction becomes routine, an eating disorder develops that diabetes professionals refer to as ED-DMT1 (Eating Disorder – Diabetes Mellitus Type 1), which is commonly called “diabulimia”3,4 by the media and lay public. Although diabulimia is not included in the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-5), insulin restriction is included as a purge symptom of anorexia (purging type) and bulimia.
In her research, Goebel-Fabbri, found that 30% of girls and women with type 1 diabetes skip or reduce necessary insulin injections to lose weight.5 This does not mean that these women meet diagnostic criteria for eating disorders, but it illustrates how widespread this dangerous behavior has become.
Those who frequently restrict insulin typically have frequent episodes of diabetic ketoacidosis (DKA), which causes vomiting, dehydration, difficulty breathing and confusion. At its most severe, a person with DKA may become comatose and may be at risk of dying.
Those who report insulin restriction triple their risk of death, while also increasing their risk of eye disease, kidney disease and nerve damage, according to 2008 research by Goebel-Fabbri.5 An 11-year study of 234 women with type 1 diabetes showed that those who restricted their insulin intake died at an average age of just 45 years old. Those who did not restrict died at an average age of 58.5
Recognizing Eating Disorders
While those with type 1 diabetes have a high incidence of eating disorders, little research has been done about which types of eating disorders they typically have.
It’s not surprising that anorexia, in which individuals severely restrict what they eat, is less common among those with type 1 diabetes, given that failure to eat meals regularly can be fatal for those with diabetes. However, anorexia still exists among those with type 1 diabetes. Individuals with diabetes and anorexia eat so little, they require very little insulin.
Nurses should recognize that, because the body’s insulin needs for those who have anorexia are profoundly reduced, their blood sugar is not at an alarming level and their anorexia may go undetected.
Anorexia has the highest mortality rate of any psychiatric illness.6 It can cause low blood pressure, an abnormally slow heart rate, reduced bone density, dehydration that can lead to kidney failure and other major illnesses. And that’s before adding on the medical complications of diabetes.
Bulimia is more common among those with type 1 diabetes. Symptoms include regularly binging by eating an excessive amount of food, feeling a lack of control over the binging and compensating to prevent weight gain by self-induced vomiting; misuse of laxatives, diuretics or other medications; fasting, or excessive exercise.
Those who have bulimia often have an electrolyte imbalance that results in irregular heartbeats, increasing the potential for heart failure. They often suffer from inflammation or tearing of the esophagus, and swollen glands, and have irregular menstrual periods and lowered interest in sex.
Individuals with type 1 diabetes may also have binge-eating disorder. Those with binge-eating disorder eat unusually large quantities of food and feel that they have no control over their eating, but they do not purge. Binge-eating disorder often leads to obesity and all of its related medical complications, including hypertension and high blood pressure.
As with people in the general population who have an eating disorder, many who have both type 1 diabetes and an eating disorder do not meet all of diagnostic criteria for anorexia, bulimia or binge-eating disorder and are classified as having an “eating disorder not otherwise specified” or EDNOS. EDNOS includes any eating disorder that fails to meet full criteria established for the disorder in the Diagnostic and Statistical Manual of Mental Disorders.
Those who have diabulimia, for example, are classified as having EDNOS. The manual is just beginning to come to terms with eating disorders, though, as binge-eating disorder was officially recognized with the 2013 publication of DSM-5. Those who have diabetes and eating disorders often also have other co-occurring disorders, such as depression and substance abuse.
Considered separately, type 1 diabetes and eating disorders are serious, life-threatening illnesses that are difficult to treat. Considered together, in a patient of any age, they pose among the most serious challenges nurses and other healthcare practitioners may ever face.
To begin with, nurses who treat diabetes typically lack training for treating eating disorders and other psychiatric disorders, just as psychiatrists and psychologists lack training to treat diabetes.
In spite of the frequency of diabetes and eating disorders occurring together, individuals with type 1 diabetes and eating disorders typically receive separate treatment for both, even though both treatments may require modifications to meet the needs of this unique population. For example, insulin dosage is determined individually, based on patients eating regular meals, but when a patient has anorexia and eats little, blood sugars and insulin needs are reduced and must be actively addressed.
Another concern is that those who have eating disorders are unlikely to manage their diabetes properly. Standard eating disorder treatment is designed to help patients relinquish their focus on food, but those with diabetes cannot be encouraged to do this, because their diabetes management requires them to focus on food to maintain healthy blood glucose levels.
Treatment of diabetes may reinforce the eating disorder and treatment of the eating disorder, without consideration of the need for glucose monitoring and supervised insulin administration may be disastrous to the patient’s health.
Based upon our experience at Walden Behavioral Care, patients with type 1 diabetes and eating disorders often receive inconsistent information about their care, because their healthcare providers typically do not communicate with each other. Without a coordinated team approach to treatment, it’s not unusual to have three different recommendations for how to treat the patient. Treatment is further complicated by a high incidence of anxiety, depression and substance abuse.
Recognizing the need for an individualized, coordinated program to treat those who have both type 1 diabetes and eating disorders, Walden Behavioral Care recently created the Type 1 Diabetes and Eating Disorder Program.
The integrated care program is one of the first in the country to treat diabetes and eating disorders concurrently, and it may be the first to provide specialized care along the full continuum of care, including in-patient, residential, partial hospitalization and intensive outpatient care.
As a first step, Walden arranged to have medical, nursing and nutrition staff trained by staff at the Joslin Diabetes Center, so that they could help patients better manage their diabetes even while treating their eating disorder.
In addition, Walden has arranged to have type 1 diabetes patients who participate in the program evaluated at Joslin. After evaluating the patient, the Joslin physician develops a diabetes treatment plan for Walden staff to follow while the patient’s eating disorder is being treated at Walden. The Joslin doctors also work with and consult with each patient’s endocrinologist, and Walden staff has 24-hour access to consulting endocrinologists from Joslin.
The new program, which is consistent with Walden’s “whole health” approach to healthcare, will provide patients with:
- Treatment that is tailored to each patient’s need at any time.
- Concurrent treatment of multiple illnesses, including not only diabetes and eating disorders, but other psychiatric disorders.
- A combination of medical, psychological, psychiatric and nutritional care, along with family therapy.
By addressing diabetes, eating disorders and any other co-occurring disorders in tandem, rather than separately, Walden can better manage treatment, creating an opportunity for optimal diabetes management and eating disorder recovery.
References for this article can be accessed here.
Stuart Koman is president and CEO of Walden Behavioral Care in Waltham, Mass. He can be reached at firstname.lastname@example.org.