Disordered eating behaviours are common in diabetes and occur along a continuum of severity with serious health consequences.
This needs to be managed by health professionals in a non-judgmental way, a packed session at the ADS conference has learned.
Queensland psychiatrist Associate Professor Warren Ward, diabetes educator and dietitian Helen d’Emden, and psychologist Carolyn Uhlmann spoke at a booked-out session on disordered eating and eating disorders in diabetes, which is 2.4 times more common in people with the disease than in the general population.
The prevalence of eating disorders in the general community has doubled in the last decade and is partly fuelled by the advent of social media, according to Associate Professor Ward director of the eating disorder service at the Royal Brisbane and Woman’s Hospital.
A study conducted by his co-presenter Helen d’Emden found that one-third of their patients with type 1 diabetes aged 18 to 30 years had signs of disordered eating.
“People with diabetes are already at an increased risk of death but when you add in an eating disorder the combined death rate falls off a cliff,” Associate Professor Ward says.
“Because the mortality rate is so high when you have both conditions we would rather identify early symptoms of an eating disorder before it becomes full blown anorexia nervosa.”
What are the warning signs?
The risk factors for eating disorders in the general population are largely well-known – young females, people with conscientious personalities, obese people and those who diet are particularly at risk.
For people living with insulin-dependent diabetes the risk factors are similar however they have a unique compensatory behaviour available to them – the ability to restrict insulin, says Associate Professor Ward.
He says the red flags that should raise a suspicion of an eating disorder are unexplained markers of poor diabetes control such as ketoacidosis and poor HbA1c.
Families may also notice an increase in concern about weight and shape, or changed behaviours such as the omission of major food groups, excessive exercise, or not giving an insulin bolus with meals and snacks.
Ms d’Emden advised diabetes health professionals to have a “high index of suspicion” for disordered eating in their adolescent patients.
Some warning signs can present at diagnosis through attitudes to the diagnosis itself and the weight changes they may experience prior to their diagnosis and on the commencement of insulin therapy, Ms d’Emden explains.
“[Diabetes health professionals] might pick up early signs in their patients by looking at behavioural changes at home and at school or just how well they are managing their diabetes, whether they are on board, whether they are capable of taking on the management tasks.”
Tread gently
People with disordered eating and eating disorders are often reluctant to disclose that they have a problem and are often fearful of judgment, explains Associate Professor Ward.
This means it’s important for diabetes health professionals to approach the topic with their patients in a non-judgmental way.
“It’s exquisitely important to say something like ‘it’s very common for people with diabetes to have problems where they sometimes don’t feel like taking their insulin or they worry about their weight and shape… if you have those concerns we have some really good services we can refer you to that can help you with this’.”
“Frame it in a positive way and really try and work on that relationship with your patient, be supportive” Associate Professor Ward advises.
Collaborative care is important
According to Ms d’Emden, disordered eating behaviours should be managed by the diabetes team in routine diabetes care.
However diabetes clinicians need to be upskilled and gain the confidence in treating such patients, something that working collaboratively with eating disorder specialists can help with.
“It’s really about the team looking at engagement with the patient, building their self-esteem and supporting self efficacy in their diabetes management” she says.
“When it’s clear that there is an eating disorder then we refer and co-manage with a specialised eating disorder service.”
In Associate Professor Ward’s experience treating people through a specialist eating disorder service in collaboration with the diabetes service is a successful way of managing patients.
“A lot of psychiatrists don’t have expertise in eating disorders and so it is better to refer patients to a specialist eating disorder service where patients can get access to psychiatrists, dietitians, and psychologists,” he says.
Through their local eating disorders service, diabetes specialists can also participate in a training course where they can increase their skills and confidence in managing disordered eating and eating disorders.
For more information on these courses visit The Butterfly foundation website here.