Emotional Support Key to Unlocking Eating Disorders in T2D

Liam Davenport

March 15, 2019

LIVERPOOL — Diabetes patients are at increased risk of developing eating disorders and need specialist care that focuses on emotional support to help them get control of their condition and improve their diabetes outcomes, warn UK experts.

Eating disorders such as anorexia, bulimia, and binge eating, as well as diabetes-specific conditions such as diabulimia, are common in type 1 and type 2 diabetes due not only to the condition but also to its treatment, delegates at the Diabetes UK Professional Conference were told.

Holistic Care Needs

At a session dedicated to eating disorders, Dr Simon Chapman, King's College Hospital NHS Foundation Trust, emphasised that traditional eating disorder units often don’t help, and patients require a focus on support and health, rather than on food specifically.

Speaking in the same session, Jacqueline Fosbury, the psychotherapy lead for diabetes care for You at Sussex Community NHS Foundation Trust, looked at binge eating disorder (BED) in diabetes.

She said that depression is often the mediating factor, and needs to be tackled directly with appropriate interventions alongside efforts to improve eating behaviours.

Approached for comment, Libby Dowling, senior clinical advisor at Diabetes UK, told Medscape News UK that the issue of eating disorders in diabetes underlines the need for holistic care in this vulnerable population.

She said: "We’re now really getting behind this idea that the emotional support for people with diabetes is just as important as the physical support.

"You can imagine the effect that either type of diabetes can have on your life, your relationships, your work, and we’re becoming aware that, if we’re going to look after people with diabetes properly, we’ve also got to look after their emotional needs."

She added that diabetes patients are "more likely to have depression, anxiety, disordered eating, and there are also specific areas of diabetes management that can cause problems, like fear of injections".

"If we’re going to look after people holistically, we’re going to have to look after their emotions as well as their physical health."

Diabetes and Emotional Health

To those ends, Diabetes UK launched Diabetes and emotional health, a guide for healthcare professionals (HCPs), at the conference. This was adapted from a similar resource published in Australia a couple of years ago.

Libby Dowling said that the intention is "to support them in looking after their patients' emotional needs, as well as their physical needs", which includes giving them tips and skills.

She noted that "a lot of HCPs are quite worried about that side of things; they don’t want to make things worse".

Libby Dowling explained that, while it is difficult to estimate the number of diabetes patients with eating disorders, it is thought that the prevalence of diagnosable eating disorders in type 1 diabetes may be 2%, rising to 10% in type 2 diabetes.

For disordered eating, or subclinical abnormal eating patterns, the prevalence is much higher.

She said: "Thinking about it, it’s not particularly surprising because, whatever type of diabetes you have, lots of things have changed around you which might affect your relationship with food.

"For example, if you’re diagnosed with type 1, you’ve often lost an awful lot of weight and then, as you get treatment for your type 1, you start to put it back on and that can feel uncomfortable."

She added: "If you’ve got type 2, you’re often overweight and then suddenly you’ve got to think about your weight…and that can upset your body image."

The treatment can also have an effect, as it’s "very food and weight focused".

Gender Differences

In his presentation, Dr Chapman underlined that young diabetic women with eating disorders have worse outcomes than those without eating disorders, including painful neuropathy and other complications.

Dr Chapman also agreed with Libby Dowling, suggesting that, paradoxically, clinicians treating diabetes may be "part of the problem" when it comes to eating disorders.

He explained that continuous weight and growth surveillance, scrutiny of food and diet, and insulin intensification could all play a role in increasing the risk of an eating disorder in young people with diabetes.

In trying to tackle eating disorders in this population, Dr Chapman said that the evidence for standard eating disorder units is "very poor".

He instead believes that the key to treating an eating disorder in this patient population is centred around family therapy, involving psychoeducation and the handing of control for meals back to parents.

This should focus on challenging the way that young people think about themselves and their diabetes.

Moreover, the eating disorder, typically anorexia, should be externalised, so that it is not seen as the patient’s choice to have the disorder but something that has happened to them that they can fight.

MaRSiPAN

To help clinicians with language around this patient group, he highlighted MaRSiPAN, or the Management of Really Sick Patients with Anorexia Nervosa, an initiative by the Royal College of Psychiatrists.

He also pointed to the National Institute for Health and Care Excellence (NICE) Eating disorders: recognition and treatment guideline, which has a section on treating people with an eating disorder who also have diabetes.

After setting out some of the criteria for suspecting the presence of an eating disorder in individuals with diabetes, Dr Chapman said that there are several steps that clinicians should take when treating a patient.

These include early referral to the eating disorders team and being upfront with patients, including focusing on the restoration of health, not weight, and emphasising the possibility of a good outcome.

He underlined that healthcare professionals should not "leave it to the psychologist", as clinicians, nurses and dietitians can have "very powerful therapeutic voices".

Parents and siblings should also be included in the care alongside the patient, as they will need support.

One example of an eating disorder in diabetes patients that can have potentially devastating consequences is that of diabulimia, in which people restrict their insulin intake to lose weight.

It is most common in individuals aged 15–30 years, and some estimates put the prevalence as high as 40% in women and 10% in men with type 1 diabetes.

However, there has been a lack of awareness about diabulimia among HCPs, although Libby Dowling said that is improving.

"People are starting to be more aware of these people who have high blood glucose levels, come into hospital regularly with diabetic ketoacidosis, [and] avoid coming to clinic," she said.

"Now people are starting to think: Could this be diabulimia? But it’s not the top of everybody’s list."

To help tackle the problem, NHS England has launched two pilot projects for the treatment of diabulimia.

As reported by Medscape News UK, these will provide eating disorder teams, specialist day care centres, and tailored care, which could include community support.

Libby Dowling said that the pilots were part of recognition by NHS England that "there isn’t a lot available for these people in terms of specialist care".

She explained: "To go to a general eating disorder service with diabetes doesn’t tend to work because those who are specialised in eating disorders don’t necessarily specialise in diabetes, and vice versa."

She added: "Once these sites start to take on patients and report their results, we’ll be in a position to say: ‘Okay, what’s working, what’s not working, how can we modify things, how can we roll it out?’

"It’s a fantastic step forward; it’s absolutely what needs to happen. We’ve a long way to go, but this is definitely the start."

BED Details

In her presentation, Jacqueline Fosbury said that BED is characterised by the rapid intake of large quantities of food over a specified period, even if the individual is already full, as well as eating while emotionally charged and having no control while eating.

In addition, individuals with BED may eat alone to prevent others knowing how much they eat, and feel guilty, ashamed, disgusted and depressed about their eating.

However, Jacqueline Fosbury emphasised that, unlike bulimia nervosa and diabulimia, BED does not involve purging.

BED is associated with weight gain, type 2 diabetes, high blood pressure, cardiovascular difficulties, joint pain and sexual dysfunction.

Depression, she highlighted, is a key feature, and mediates the interaction between BED and type 2 diabetes.

She said that the prevalence of BED in type 2 diabetes ranges from 20% to 26%, depending on the study, and is partially driven by carbohydrate craving due to insulin resistance.

Jacqueline Fosbury explained that there are a number of tools to screen for BED, although they may not be specific to type 2 diabetes or BED. Consequently, Diabetes Care for You is constructing its own questionnaire.

For her, the primary approach to treating BED in type 2 diabetes is to deal with the patient’s depression and tackle the underlying difficulties that have caused the condition.

She said that psychotherapy, antidepressant medication and eating-disorder-focused cognitive behavioural therapy can all be used, with the NICE guideline recommending an initial focus on eating behaviours.

The charity Beat also provides an eating disorder helpline, and runs online support groups for family and friends.

Help can also be found, Jacqueline Fosbury said, from a diabetes dietitian.

For example, if binge eating is triggered after eating fast-acting carbohydrates, "it may help to switch to less quickly-absorbed sources of carbohydrates, such as wholegrain foods".

It may also be beneficial for patients to reduce their overall carbohydrate intake to lower blood glucose levels after meals and reduce feelings of hunger.

No funding or conflicts of interest declared.

Diabetes UK Professional Conference: Eating disorders and disordered eating in Type 1 and Type 2 diabetes. Presented March 7th 2019.

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