Special groups

Eating disorders and diabetes

Khalida Ismail

Abstract
Diabetes mellitus is characterized by chronic hyperglycaemia and its in cidence is rising rapidly in parallel with the obesity epidemic. Disordered eating, especially sub-threshold eating disorders, is a common psychologi cal problem in both type 1 and type 2 diabetes, and Is associated with poor diabetes control, complications, and an increased mortality rate. As sessment requires a consideration of the risk factors for eating disorders and for poor diabetes control, and should include the inappropriate use of insulin (omission or reduced doses) as a means of purging in type 1 dia betes and avoid becoming overweight in type 2 diabetes. Eating problems tend to co-exist with other psychological difficulties, especially depression, which should be actively treated. There have been insufficient studies to establish an evidence base for a psychotherapeutic approach to managing eating problems in patients with diabetes, but generic psychological mod els from eating disorders could be adapted to address diabetes-related coping problems, such as fear of needles or of hypoglycaemia.

Keywords bariatric surgery; diabetes complications; diabetes mellitus;

disordered eating; eating disorder; epidemiology; morbid obesity; psychological treatments

groups. The pandemic of diabetes and obesity is estimated to increase the number of people with diabetes worldwide from 194 million in 2003 to 333 million in 2025.5 There are four types of diabetes.6,7 Type 1 diabetes is due to autoimmune destruction of -pancreatic cells leading to absolute loss of insulin production.8 The onset is typically in childhood, but occurs at all ages. Type 1 diabetes represents between 10% and 15% of all cases of diabetes. It has a rapid onset from a few weeks to months, and is characterized by fatigue, weight loss, polyuria, and polydipsia. There is often a honeymoon phase during the first year in which the physiological need for exogenous insulin is transiently less and glycaemic control is deceptively good, during which there may be rapid weight changes. The incidence of type 1 diabetes is increasing at 3% per year worldwide.9 Type 2 diabetes is characterized by insulin resistance and insulin deficiency relative to the prevailing glucose levels. Type 2 diabetes represents around 8595% of all cases of diabetes. Factors associated with an increased risk for type 2 diabetes are obesity, being of African and Indian subcontinent descent, decreased physical activity, and a genetic predisposition. The mean age of onset is usually in the forties, but is decreasing, especially in high-risk populations secondary to the obesity epidemic. The other types includes gestational diabetes, which can develop into type 2 diabetes, and those secondary to other causes such as alcoholic pancreatic failure. Two landmark multicentre randomized controlled trials have demonstrated that intensive medical management, such as mul tiple insulin injections in type 110 and initiation of insulin therapy in type 211 diabetes, can improve glycaemic control and reduce the rate of complications, but in both types of diabetes optimization of glycaemic control was associated with weight gain.

Epidemiology of eating disorders in diabetes mellitus Introduction

Diabetes mellitus is one of the most common chronic diseases worldwide and is characterized by chronic hyperglycaemia which leads to macrovascular and microvascular complications. At present, there is no cure and people with diabetes have to be responsible for multiple self-care tasks such as administering insulin injections and oral medication, monitoring a specified diet, exercise, weight reduction, vigilance of injection sites and footcare. Although depression is the most common psychological problem in diabetes,1 disordered eating is increasingly being recognized, and both psychiatric conditions have been given special attention in national and international guidelines for the management of diabetes.24 Type 1 diabetes Several studies have assessed the prevalence and incidence of eating disorders in type 1 diabetes.1214 In a systematic review of controlled studies of female patients with diabetes compared with non-diabetic controls,15 the prevalence of anorexia nervosa was not significantly increased (0.27% vs 0.06%) but that of bulimia nervosa was significantly greater (1.73% vs 0.69%); when both conditions were considered, the prevalence was also significantly increased (2.00% vs 0.75%). Eating attitudes and behaviours defined as subthreshold/subclinical or disordered eating are nearly twice as common, affecting 14% of young females with diabetes compared with 8% of non-diabetic controls.14 Eating disorders and disordered eating are associated with suboptimal glycaemic control, an increased risk of complications such as retinopathy, and death.14,16,17 There is a small subgroup of young (typically) women who have severe problematic diabetes control manifested by severe fluctuations in glucose levels, recurrent life-threatening diabetic keto-acidosis, and recurrent severe hypoglycaemia in the context of severe chronic poor glycaemic control. Patients in this group, once labelled as having brittle diabetes, tend to have underlying specific mental health problems, including dysphoria, weight and body image disturbance, and features in keeping with the borderline personality spectrum. Over years, this clinical pattern may change into overt recurrent vomiting. Teasing out
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Clinical features of diabetes mellitus

The prevalence of detected diabetes is around 35% in the general population and up to 1020% in certain high-risk ethnic

Khalida Ismail MRCPsych is Senior Lecturer in Liaison Psychiatry at the Institute of Psychiatry, Kings College London. She is also a Consultant Psychiatrist at the Diabetes Centre at Kings College Hospital, London. Conflict of interest: none declared.

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Special groups

past and current eating problems has to be assessed in the presence of diabetic complications such as autonomic neuropathy and chronic hyperglycaemia, both of which are also causes of gastroparesis.18 Type 2 diabetes The relationship between type 2 diabetes mellitus and eating disorders is less well documented and recognized than in type 1 diabetes. Binge eating disorder19 and the night eating syndrome20 are commonly recognized in overweight and obese persons,21,22 and have been suggested as distinctive clinical entities in the spectrum of overeating.23 The prevalence of binge eating disorder ranges very widely from 13% to 25% depending on the characteristics and methodologies of individual studies,2427 and around 10% have subclinical binge eating problems.28 The increase in eating disorders in type 2 diabetes is confounded by the association of disordered eating with obesity, which is on the causal pathway to type 2 diabetes. Night eating syndrome, which is characterized by a delay in the circadian pattern of eating, such that at least 25% of the daily total caloric intake occurs after the evening meal and/or there are at least three nocturnal awakenings per week accompanied by eating,20 has a prevalence of 3.8% in diabetics. It may be related to increased appetite following evening insulin administration and/ or the fear of having nocturnal hypoglycaemia.27 Risk factors for eating disorders include younger age,28 higher body mass index,25 and depressive symptoms.24,25,29 Although glycaemic control is not always associated with binge eating,24,25,29 this group of patients is still at high cardiovascular risk secondary to their obesity.

Theoretical model of potential pathways to disordered eating in type 1 diabetes

Family Dysfunction Family psychiatric history Marital discord Body size as child Developmental factors Age of onset Carer characteristics

Onset of diabetes Personality development Perfectionistic Impulsive Stigma and peer environment School Workplace

Rapid weight changes during insulin initiation Skills/confidence in diabetes self-care

Disordered eating Depression

Diabetes-related fears Fear of hypoglycaemia Fear of injections Figure 1

Suboptimal glycaemic control

Management
The first step in managing disordered eating is detection, which can be more difficult than in those who do not have diabetes as both patients and diabetes teams may attribute problematic diabetes control to medical causes such as the insulin regimen. One of the key issues is the fear of weight gain on insulin and balancing the ability to lose weight rapidly (sometimes up to 5 kg overnight in type 1 diabetes) by omitting insulin with the perceived risk-taking for acute (e.g. keto-acidosis) and long-term complications (e.g. loss of vision). The diagnosis of eating disorder should include an assessment of deliberate inappropriate insulin use as a purging method. The assessment should take into account the risk factors for eating disorders but also include the psychological and social impact of living with diabetes, such as adjustment versus denial of diabetes, stigma and shame, family factors (especially maternal psychopathology),3032 and other diabetes-specific fears and worries such as anxiety about hypoglycaemia, fear of self-testing and injecting (or frank needle phobia), and fear of complications.3335 Some of the pathways to consider are illustrated in Figures 1 and 2 for type 1 and 2 diabetes respectively. Poor glycaemic control, repeated episodes or admissions for diabetic keto-acidosis or hypoglycaemia, or fluctuations in body weight are important triggers for a psychiatric assessment. Sensitive, gentle, but direct enquiries about attitudes to body shape and weight, portion sizes, and methods of weight management should be made, sometimes over several consul tations careful listening is needed to elicit subclinical eating
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Complications of diabetes

issues. For instance, following a hypoglycaemic episode (blood glucose < 4.0 mmol/litre) it is appropriate for patients to eat glycogenic foods such as a sugary drink and biscuit, but some patients treat themselves with a binge, which can swing the blood glucose level to the high end. This leads to a vicious circle of negative cognitions (such as an increasing belief of failure) and increasing psychological distress in chasing the blood sugars in order to correct them. In people with type 2 diabetes, increasing doses of oral hypoglycaemic agents and insulin with no clinical response should raise the possibility of psychiatric morbidity. Screening questionnaires specifically for eating disorders or for diabetes-related coping may help, as may adopting a motivational interviewing style.3638 Assessment and management of depression (and other psychiatric disorders, such as needle phobia) are critical as, once mood has improved, the patient may be more comfortable about divulging eating problems. Therapeutic interventions generic to psychiatry and to eating disorders are applicable to people with diabetes but are most likely to be effective when the therapist is experienced in working in a range of chronic disease settings or has psychological skills in treating patients with diabetes.39 Educational material about diabetes should be updated and structured educational programmes to improve the flexibility of insulin administration to match the amount of carbohydrate should be considered,40

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Special groups

Theoretical model of potential pathways to disordered eating in type 2 diabetes

Vulnerability factors Social adversity Knowledge Cultural factors Beliefs about diabetes, insulin, and body image

the distress of frequent insulin injections and give the patient confidence in managing everyday activities.48 Alternatives such as islet cell transplantation and total pancreatic organ transplant are still research technologies. Bariatric surgery is a recommended treatment for morbid obesity and, again, may be the necessary first step before the binge eating disorder can be tackled, although psychological treatments should be considered and offered first; the decision to operate has to be on a case-by-case basis and within a collective multidisciplinary decision-making process.49

Long-standing overeating bingeing Obesity

Summary
Disordered eating is a common psychological problem in people with diabetes and is associated with poor diabetes control, complications, and increased mortality. It is often present with other psychological problems, such as depression. The threshold for clinical significance for eating problems in diabetics should be lowered. The detection, assessment, and management is often limited because of lack of psychological skills and referral pathways in diabetes centres. The evidence base for diabetes-specific psychotherapeutic approaches to managing eating problems per se is still in its infancy, although there is some evidence that psychological treatments can improve glycaemic control. Future research should focus on developing a better understanding and integrating the psychological and physiological mechanisms for disordered eating in diabetes, which in turn should inform more focused psychological interventions.

Depression

Onset of type 2 diabetes

Difficulties in adhering to diabetes self-care Progression of disease

(Fears of) weight gain on insulin therapy

Suboptimal glycaemic control

Complications of diabetes

Figure 2

although anecdotally binge eaters are at risk of putting on weight as they titrate their insulin doses accordingly. Good communication and joint meetings between the mental health team and the diabetes team can improve the chances of therapeutic success. There have been a handful of randomized controlled trials of psychotherapeutic interventions specifically for eating problems, but only in type 2 diabetes.41,42 For type 1 diabetes, several promising case series have been published.4345 A systematic review and meta-analysis of randomized controlled trials46 provided some evidence that psychological treatments (predominantly variants of cognitive behavioural therapy) were effective in improving glycaemic control in adults with type 1 diabetes, although the findings were not statistically significant. On the other hand, there is some evidence that psychological treatments, and perhaps a family-based approach, may be more effective in children and adolescents with type 1 diabetes46 and in adults with type 2 diabetes.47 In both conditions, psychological distress was reduced. One should be mindful that the patient and therapist may agree not to focus on eating problems, as the patient may be distressed by other psychological issues that are also associated with poor glycaemic control, such as fear of hypoglycaemia. Sometimes taking a medical rather than a psychological approach to tackling an eating disorder may be the option that the patient prefers. For instance, the continuous subcutaneous insulin infusion pump may alleviate
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