The practical management of patients with type 1 diabetes requiring in-patient care due to an eating disorder

IntroductionYoung women with type 1 diabetesare at increased risk of eating disor-ders, particularly bulimia nervosaand EDNOS (Eating Disorders NotOtherwise Specified). This group ischallenging to manage, especially inpatients who require hospital admis-sion due to their eating disorder.Little has been published on clinicalmanagement practices of profession-als working with these individualsduring in-patient treatment.1–5 Casestudies,5–8 a description of cognitivebehavioural therapy in anorexia ner-vosa9 and research assessing psycho-educational interventions10,11 in at-risk young women have been pub-lished. This paper discusses our clin-ical experiences in managing thesepatients at an in-patient level, andpresents a case example.

The risk of eating disordersin type 1 diabetesResearch over the last 15 years hasexamined the incidence and preva-lence of eating disorders in thisgroup. While earlier studies pro-vided conflicting results as towhether there was an increased risk,the lack of findings was partly due tomethodological difficulties.12–15

The most recent studies haveshown: • The risk of a young adult with dia-betes developing an eating disorderis approximately double that of thegeneral population.16–18

• The most common disordersdetected are bulimia nervosa andEDNOS with fewer reported cases ofanorexia nervosa.12,18

• The most common weight losingbehaviour is insulin misuse,18 whichis more common than other weightlosing behaviours such as vomitingor laxative misuse.14

• A high percentage of young adultsmisuse insulin in order to controlweight,14,19–23 and not all of thesepeople will meet diagnostic criteriafor an eating disorder.15,23–25

• There is earlier onset of complica-tions and more severe complicationsin those young adults who misuse

insulin and have eating psy-chopathology.18,20,22,26

There are aetiological factors thatpredispose or precipitate a youngadult with diabetes to develop aneating disorder. Current researchin eating disorders is focused on:individual psychological traits suchas obsessionality, perfectionism,anxiety; social and cultural influ-ences such as poor body image; psychiatric influences and mentaldisorders such as depression andobsessive compulsive disorder; and biological and familial influ-ences such as genetic background,

Pract Diab Int June 2005 Vol. 22 No. 5 Copyright © 2005 John Wiley & Sons, Ltd. 165

The practical management of patients withtype 1 diabetes requiring in-patient caredue to an eating disorderS Hart, S Twigg, S Abraham*, J Russell

PRACTICE POINT

ABSTRACTYoung women with type 1 diabetes are at twice the risk for the development of an eatingdisorder compared with their peers. When an eating disorder co-exists with diabetesthere is an increased risk of earlier onset of diabetes-related complications as well asmore severe complications. There is limited knowledge of how to detect eating disordersin individuals with diabetes and how best to manage the condition. This paper discussesour experiences in managing young adults, with type 1 diabetes and an eating disorder,at the specialist in-patient level where team members are experienced in managing bothillnesses. We highlight specific management issues at the in-patient level and present acase example. It is challenging to manage such patients because the day-to-daymanagement issues of diabetes often tend to overwhelm psychiatric interventions,particularly if eating disorder staff are less experienced in diabetes management. Aspsychiatric issues are difficult to manage by the diabetes team, the needs of a youngadult with diabetes and an eating disorder are hard to meet. Addressing diabetesspecific concerns as well as weight and shape concerns is essential, as is a well co-ordinated management team addressing both eating disorders and diabetes.Copyright © 2005 John Wiley & Sons, Ltd.

Practical Diabetes Int 2005; 22(5): 165–170

KEY WORDSeating disorders; anorexia nervosa; bulimia nervosa; diabetes; complications; screening;in-patient treatment

Susan Hart, BSc, Master of Nutrition andDietetics, Accredited Practising Dietitian,Eating Disorder Program, Northside Clinic,Greenwich; and Diabetes Education Centre,Royal North Shore Hospital, St Leonards,NSW 2065, AustraliaDr Stephen Twigg, MBBS(Hons), PhD,FRACP, Senior Lecturer, Discipline ofMedicine, University of Sydney, AustraliaAssociate Professor Suzanne Abraham,

PhD, Co-Director of the Eating DisorderProgram, The Northside Clinic, Departmentof Obstetrics and Gynaecology, Universityof Sydney, AustraliaAssociate Professor Janice Russell,MBBS, MD, MFCP, FRACP, FRANZCP,Medical Director of the Eating DisorderProgram, The Northside Clinic, Departmentof Psychological Medicine, University ofSydney, Australia

*Correspondence to: Professor SuzanneAbraham, Department of Obstetrics andGynaecology, Royal North Shore Hospital,St Leonards, NSW 2065, Australia; e-mail:[email protected]

Received: 24 November 2004Accepted in revised form: 2 February 2005

PP Abraham 118.04.qxp 10/6/05 10:53 am Page 1

timing of onset of puberty, and fam-ily history of parental mental ill-ness.27 The additional factors thatmay precipitate eating problems in a young adult with type 1 dia-betes are:• The onset of diabetes as a lifestress.28

• The effects of diagnosis of dia-betes on family functioning anddynamics.• Anxieties about short-term issuesin diabetes management such asepisodes of hypoglycaemia,29

episodes of diabetic ketoacidosis,and the potential of complicationsin the long term.• A feeling of loss of control overone’s body, which is associated withmanagement of diabetes and dailylife.28 Fearing loss of control is a cen-tral feature of eating disorders. • The focus of diabetes manage-ment is expressed through ‘control’,i.e. control of blood glucose, controlof food or dietary restraint,14,16,20,30

and control of weight as necessaryfor successful management.30,31

Families and health professionalspraise control of food and bodyweight. • The ease by which insulin can bemisused to control body weight. Theresults of manipulating insulin dosecan be rapid.16,32

• Tight glycaemic control in type 1diabetes is associated with a heavierbody weight than non-diabeticpeers21,33,34 and intensification ofglycaemic control in type 1 diabetescommonly leads to an overweightstate;14,21,35 heavier body weight pre-disposes to greater body image dis-satisfaction.16,21,36 Weight gain ispotentially unsettling for those individuals with a high value placedon control of body weight28 and the risk of weight gain is likely to exacerbate fear in vulnerableindividuals. • Frequent attempts at dieting orstrict rigid attention to food.16,25

Dieting, and restrictive eating, aremajor risk factors for the develop-ment of an eating disorder.Inflexibility about food choices displayed in a young adult requiresattention. The reason given may be ‘it’s because of my diabetes’ and not because of weight andshape.

Detecting an eating disorderin type 1 diabetesIt has been suggested that the mostcommon indicators of eating pathol-ogy in a young adult with diabetesare an elevated HbA1c level,12,16,18,28

a disclosure of insulin misuse (evenif infrequent),12,19 and body imagedisturbance.23 There may bepatients who show no signs of eatingpathology, presenting as well man-aged, and in fact have anentrenched eating disorder. That isone of the challenges that face thediabetes care team – it may beimpossible to really know unless apatient chooses to openly admit theissue to the treating health profes-sional. Many sufferers may gounrecognised.37 Patients with eatingproblems do not often present fortreatment to their diabetes careteam, or even to those people whoare experienced in treating eatingdisorders.16 The patients we haveidentified as being ‘at risk’ at pre-sentation to our diabetes centre arereluctant to engage in treatmentand have ‘dropped out’ of treat-ment by the second or thirdappointment. They present to dis-cuss issues about hypoglycaemia,chaotic eating behaviour, weightgain or erratic blood glucose levelsand want a concrete prescription toaddress these issues, rather thanattend directly to discuss eating

problems.38 They have seemedreluctant to discuss coping skills andstrategies, or to accept a referral tothe team psychologist. Engaging aperson with an eating disorder isalways difficult. The nature of aneating disorder is often secretivewith patients going to great lengthsto keep their disorder hidden.Referrals for psychiatric interven-tion are considered later rather thanearlier in complicated diabetes,meaning that patients with mentalhealth problems often go unnoticedin diabetes clinics.4 It may be that bythe time patients access a specialisteating disorder team, their disorderis long-standing. This has a majorimpact on the young adult with dia-betes because of the likelihood thatby the time they present suchpatients may already have significantdiabetes-related complications.

Clinical management issuesand recommendations for treatmentWhile papers refer to the impor-tance of screening,12,20,37 earlydetection and intervention,2,16,39

anti-dieting and anti-deprivationalstrategies,5,10,20,21 less has been doc-umented about clinical manage-ment strategies in this patientgroup. Our clinical experience iswith young adults with type 1 dia-betes who are referred to an estab-

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Managing eating disorders in patients with type 1 diabetes

Table 1. Management issues for in-patient staff

Eating disorder ward staff may need help with:

• Anxiety about fluctuating blood glucose levels, even when thesefluctuations are what would be considered normal by a diabetes careteam

• Unrealistic expectations of what constitutes satisfactory glucose control• A frequently expressed fear that ‘something’ is going to go wrong• Anxiety about hyperglycaemia with the expectation that blood glucose

levels should always be ‘perfect’. If the blood glucose levels wereelevated staff tended to believe the patient was ‘non-compliant’

• Staff may not always be up to date on when or how to use glucagon orwhat types of foods are best for ‘hypo management’. They may wait for apatient to self-report hypoglycaemic symptoms rather than initiatehypoglycaemia treatment when blood glucose levels fall below 4mmol/L.Hypoglycaemia risk may also be conferred by the eating disorderparticularly if patients are underweight,41–43 possibly due to the inhibitionof gluconeogenesis, the dysfunction of alpha pancreatic cells/glucagonproduction in response to low blood glucose levels, and the lack ofamino acid precursors for gluconeogenesis

• Anxiety about insulin injections if the patient is hypoglycaemic – wantingto withhold the next insulin injection


lished specialist eating disorderteam. The team dietitian is experi-enced in both the management ofeating disorders and diabetes. Theprogramme is a 12-bedded in-patient unit that involves structuredmeals and snacks each day with one-hour supervision after meals. Thereis a structured programme of groupand individual therapy. At admissiona care plan is implemented with theaims of weight gain in anorexia ner-vosa or control of eating disordersymptoms in bulimia nervosa. Ingeneral in the early stages of treat-ment for an eating disorder, thefocus is always on providing ade-quate calories and nutrients, andsupport to cease weight loss behav-iours such as vomiting. Very simplestrategies are used such as a nursesitting with a patient encouragingher to finish her meal. Attemptingpsychotherapy at this stage is diffi-cult due to the effects of starvation,so not too much is expected in the early stages of treatment, until a patient is well nourished.Establishing a trusting and support-

ive environment during admissionhelps engage patients as an out-patient. The aim in engagingpatients is to help them realise thatthe team have a genuine interest intheir wellbeing and an appreciationof the struggle to separate and let goof their disorder. The team worksvery hard to avoid entering into abattle with the patient for control ofthe disorder, and aims for collabo-rating with the patient, against the disorder.

Management challengescommonly observed duringhospital admission• These are summarised in Table 1and discussed in more detail below.• The intense medical interventionthat is essential in managing dia-betes such as insulin management,blood glucose monitoring and hypo-glycaemia management is a chal-lenge to the eating disorder teamwho have less exposure to diabetesmanagement. • Implementing a traditional dia-betes dietary regimen with the

needs of a patient with an eating dis-order.5 In particular, health profes-sionals with less exposure to dia-betes can be focused on the ‘no-sugar’ restrictive regimens of thepast, and the outdated belief thatthe presence or absence of ‘dietarysugar’ is the only dietary factor thathas an impact on glycaemic control.The liberation of diabetes regimensregarding the inclusion of sugar inthe diet as well as inclusion of awider variety of foods needs to beappreciated.40 Dietary educationneeds to be provided to the staff aswell as the patient.• The diabetes health professionalmay not be familiar with majormanipulation of caloric intake,including carbohydrate intake,simultaneous with attempts atmanipulation of insulin dosage,which may occur in this group of in-patients.5 Restricting patient accessto insulin and observation of insulinadministration are commonly neces-sary. Providing guidelines in rapidacting mealtime insulin dosingrelated to often variable carbohy-drate intake, and ready access to dia-betes specialists to help in decisionsabout modifying insulin therapy aregenerally required. Through theirillness behaviour, these patients areprone to marked swings in bloodglucose levels and a ‘safety first’approach, to avoid severe hypogly-caemia and also diabetic ketoacido-sis, is necessary. • Suggested practical managementstrategies for such in-patients arelisted in Table 2. These strategiesrely upon an accessible multidisci-plinary health care team, good writ-ten and verbal communicationacross team members, a fundamen-tal knowledge base about managingboth eating disorder and type 1 dia-betes, being prepared especially forhypoglycaemia, and providing aconsistent management message tothe patient.

It is well accepted that many patientswith a major eating disorder maynot make appropriate decisionsabout optimal nutrition and caloricintake. If they have type 1 diabetes,they will also be prone to make suboptimal decisions about gly-caemic control, often undertreating


PRACTICE POINT


Table 2. Practical management strategies at the in-patient level

• Continuing staff education – provide in-services, diabetes education, andeasily accessible literature

• A ‘hypo kit’ on the ward with instructions in how to treat hypoglycaemia• Access to an ‘on-call’ endocrinologist who is prepared to have regular

contact with the staff and patient. This is useful in minimising staffanxieties and for providing a supportive environment for the patient. On-call enquiries for the endocrinologist are usually in regards tohyperglycaemia and adjusting insulin doses

• An experienced dietitian who is skilled in both diabetes management andeating disorders. On-call enquiries for the dietitian include queries suchas, ‘do we still give the patient dinner if blood glucose levels are above12mmol/L?’

• Clear instructions and information to nursing staff for times whenendocrinologist and dietitian are not available

• Setting a well-defined treatment plan with the aim of avoiding confusionbetween staff. There is a danger that the eating disorder team becomesso focused on diabetes management and its day-to-day issues that verylittle psychological work is attempted.5 The diabetes specialist maypotentially be used as an alliance for the patient with the eating disorder,to avoid treatment aims such as weight gain – i.e. a patient may requestthat she does not have to eat ‘high-energy’ foods as it isn’t good for thediabetes even though it may be necessary for weight gain

• Regular meetings and rapid, clear lines of communication are essential. Aclearly defined plan of ‘who is treating what’ with well-establishedboundaries is necessary

• Close supervision of the patient when injecting insulin and testing bloodglucose levels

• Reassurance to staff as well as the patient that the eating disorder anddiabetes are being managed


hyperglycaemia to lose weight.Particularly in such patients who areunwell enough to require hospitali-sation, we firmly believe that at ini-tial hospitalisation, in addition toissues of amount and type of caloricintake, decisions about glycaemictargets and insulin doses should beremoved from the patient. As thepatient adjusts to accepting that theyare receiving therapy, increasedpatient autonomy can be fostered –in a supportive environment of deci-sion making about diet, insulin ther-apy and blood glucose levels.Hopefully, by the time of hospitaldischarge, at least some patients willbe taking an approach to their dia-betes management that minimisesthe impact of eating disorder and isoptimal to their overall health.

Case studyJane, a 27-year-old woman with aneight-year history of anorexia ner-vosa, developed type 1 diabetes atage 19 and was started on insulinfrom diagnosis. Her weight was41.7kg (body mass index14.8kg/m2) at admission and shewas admitted for medical stabilisa-tion and refeeding. At admission,biochemistry was relatively normal,apart from dehydration and anHbA1c level of 12% and a randomblood glucose level of 19mmol/L.Her weight losing behaviours wereinsulin misuse, vomiting and restrict-ing food intake with episodes ofbinge eating. She had been admittedto non-specialist hospitals in the pastfor short durations but had neverhad treatment for her eating disor-der. She reported several admissionsfor diabetic ketoacidosis, some inves-tigations and complications screen-ing but was vague in reporting pre-cisely what these were. She had seena number of endocrinologists buthad never remained in treatment forlong. She did not have a GP andtended to visit GPs randomly for herinsulin prescriptions. At admissionshe described an ‘all or nothing’approach to management describ-ing episodes of tight glycaemic con-trol with an HbA1c less than 7%, regular monitoring and adherenceto diabetes self-care, alternating withpoor control and little attention toall aspects of diabetes self-care. On

assessment with the dietitian shedemonstrated good knowledge andunderstanding of diabetes dietaryprinciples. She was placed on a stan-dard refeeding diet of the eating dis-order programme, with the dietitiantaking the approach of an anti-diet-ing, non-deprivational eatingstyle5,10,20,21 consistent with eatingdisorder treatment. Carbohydrateintake was regulated to follow a por-tion controlled carbohydrate intakeof three meals and three snacks con-sistent with the eating disorder pro-gramme, with an additional bedtimesnack to help prevent nocturnalhypoglycaemia. Educational mater-ial was provided to all ward staff todescribe the rationale for dietaryprescription, and basic diabetes edu-cation (Table 3). Key ward nursingstaff attended the regional diabetescentre for an update on formaliseddiabetes education. A challenge wasstaff adjustment to the anti-depriva-tional, anti-dieting strategies in thecontext of diabetes.

Unexplained episodes of hyper-glycaemia were present for the dura-tion of the admission. At times thepatient was confronted with beingdishonest when staff could not makesense of ‘unexplained’ high bloodglucose levels rather than appreciatefactors outside the patient’s controlwhich could contribute to hypergly-caemia. This did not contribute toan ideal therapeutic environment.

From an eating disorder per-spective the patient engaged intreatment and did well, gaining11.5kg over 15 weeks, to a BMI of18.9kg/m2. She worked well ingroups and in individual psy-chotherapy, and with psycho-educa-

tional strategies. The latterincluded: discussion of attitudesand beliefs about food, compatiblefor both an eating disorder and diabetes management; and diabetesself-care. Messages of psycho-educa-tion included: that a wide variety offoods including some ‘high energysnack foods’ are compatible withgood glycaemic control; how toincorporate these snacks into a car-bohydrate controlled meal plan;and that good control does notexclude a stable normal weight.Psycho-education addressed her ‘allor nothing’ approach to eating,body weight and diabetes self-care.

When the patient presented fortreatment her insulin dose was basedon her low weight and limited foodintake. As she increased her foodintake and gained weight over thecourse of admission frequent adjust-ments to insulin doses were neededas she progressively ‘out grew’ herinsulin dose. From a diabetes per-spective, while reasonable controlwas maintained during the admis-sion, with most blood glucose levels4–10mmol/L, it was evident that she had significant complications.Medical records from five years ear-lier, when she was attending appoint-ments with a gastroenterologist,showed gastroparesis and autonomicneuropathy (also described in Pitel etal.3). This seemed to worsen as shegained weight and started eatingmore food as she developed fat mal-absorption. These symptoms hadbeen diagnosed five years earlier andrestrictive eating, such as use of non-fat and diet foods, would controlthem somewhat. She was suspectedof taking laxatives, which she denied,

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Table 3. Education provided about diabetes to staff on the eating disorder unit

• Pathophysiology of type 1 diabetes• The role and action of insulin including different types of insulin available• Injection devices• Blood glucose monitoring technique, blood glucose targets and HbA1c

• Treatment of hypoglycaemia, including use of glucagon• Managing hyperglycaemia• The role of carbohydrate including carbohydrate exchanges, the

Glycaemic Index and the role of sugar in managing blood glucose levels• The inappropriate use of artificially sweetened products, which were not

useful in promoting weight gain, or attitudinal change for this patient• The effects of insulin omission• Screening for end-organ diabetes-related complications


because of frequent diarrhoea whichwas likely to be a result of malabsorp-tion. Interestingly, she had identifiedfoods she could not tolerate andwould subsequently overeat these inorder to induce diarrhoea – a substi-tute for laxatives. She was dischargedto intensive out-patient treatment forone month at the same treatmentcentre, as a transitional strategybefore returning to her home whichwas geographically isolated and hadlimited diabetes and eating disorderservices. We aimed to engage herwith services in her local community;however, she discontinued treatmentafter one week and did not completeher transitional treatment pro-gramme. Contact was made with herapproximately two years later.Remarkably, she had had a successfulpregnancy. She described ongoingmajor eating disorder symptoms andconsidered that she may require fur-ther hospital admission for eating dis-order management.

ConclusionManaging the young adult with type1 diabetes and an eating disorder is achallenge. It is difficult attempting tojuggle the control and diligence thatare necessary for successful manage-ment of diabetes, with cessation ofdietary restraint, less focus on weightcontrol and the lessening of restric-tive attitudes.19 The question con-stantly needing to be addressed is: ‘Isone illness being managed with, or atthe expense of, the other?’ It is cer-tainly a delicate balance to managediabetes in a flexible way, to have rea-sonable and safe glycaemic control,promote diabetes self-care, eat in anon-deprivational way5,10,20,21 andmanage body weight. Addressing dia-betes specific concerns as well asweight and shape concerns is essen-tial.8,16 We recommend a well co-ordinated management team withexperience in managing both eatingdisorders and diabetes.3,5,19 It isimportant to identify those patientswith type 1 diabetes at risk, and toengage them and then retain themin treatment for the long term.

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PRACTICE POINT


Key points

• The management of patients with type 1 diabetes and an eating disorderis difficult and challenging, and there is limited literature available onclinical management and treatment strategies

• This paper highlights our clinical experience in managing young adultswith type 1 diabetes and an eating disorder at the in-patient level. Itdiscusses management issues that arose during the course of treatmentto deal with these issues, using one case example

• To manage these patients optimally, it is necessary to have a wellco-ordinated multidisciplinary team approach with access toprofessionals who are experienced in both diabetes and eating disorders

• Attention can focus on the management of diabetes rather than onpsychiatric and psychological care particularly if professionals have lessexperience in dealing with diabetes-related issues

• Addressing diabetes specific concerns as well as weight and shapeconcerns is essential in the management of these patients

• It is difficult to detect at-risk individuals with eating disorders prior to thedevelopment of a crisis

• Whilst treating crisis periods is critical in its own right, it is also commonlydifficult to retain these individuals in follow-up treatment after the crisis


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The practical management of patients with type 1 diabetes requiring in-patient care due to an eating disorder