Dr Vicki Dunbar, Clinical Psychologist
NHS Tayside Service for Diabetes in the Young
NHS Tayside CAMHS
North of Scotland Young People’s Inpatient Unit
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Clinical Psychologist
CAMHS ED
CAMHS Inpatient YPU
Paediatric Diabetes Psychologist
Type 1 diabetes
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Disclaimer: On maternity leave!
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Introduction
Examine some of the complexities of assessing
and treating eating disorders in young people with
type 1 diabetes
Looking at case studies from clinical experience
Think about some practical resources and
information to take back to clinical practice
Questions!
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Type 1, Type 2 diabetes are just different levels of severity
of diabetes (Type 1 is most severe)
T1D is caused by eating sugary foods and a unhealthy diet
Type 1 diabetes (T1D) is treated using insulin injections
and frequent blood testing
You can grow out of T1D
Having T1D doesn’t stop you from doing anything you want
in life
If you were diagnosed when you were younger, you’ll be
used to it and it wont affect you as much psychologically.
T1D is a hidden disability
HbA1c is a measure of blood sugar levels in real time.
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Caused by a number of factors, genetics, viral
hypothesis (and a few more theories emerging).
Is an autoimmune disease
Co-morbidity to coeliac, rheumatoid arthritis,
hashimotos thyroiditis (watch for differential
diagnosis)
Can be diagnosed within 3 peaks (toddler, 9-12,
15-17). Often weight loss is a key component
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Body needs fuel, insulin acts as a key to let sugar into the cells.
Without insulin, body doesn’t get energy and can go into
‘DKA’ which can be fatal. If body cant get store energy, weight
loss can occur. Needs daily insulin replacement by injection or
pump, matched to energy output (exercise) and energy input
(food) as well as hormonal fluctuations, stress, illness etc.
Intensive focus on food, eating and exercise as part of
treatment. Weight often a focus at clinic appointments.
Insulin doesn’t put weight on per se, but more insulin means
more food required to balance sugar levels. Often you see
weight gain after diagnosis and effective treatment has been
established.
Hypos must be treated with high sugar foods to raise sugars
levels rapidly. Hypos are “scary – why would you want to have
one?”.
Requires regular physical monitoring from MDT.
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Young people with T1D are twice as likely to develop
an eating disorder than a person without diabetes
(Rodin et al., 2002). Sub-threshold eating disorders
also twice as likely (Rodin et al., 2002).
Focus on weight and food
Co-morbid psychological difficulties much more likely,
dealing with chronic illness (Depression, anxiety in
particular)
‘easy’ way to lose weight – to stop/ reduce insulin....
Presence of INSULIN OMMISSION found to be up to
39% for weight control (Rydall et al., 1997)
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Usual risk of low weight e.g. osteo/fertility etc.
Risk of retinopathy
Neuropathy
Macropathy
Renal failure
Death (Diabetic Ketoacidosis; See Rodin et al.,
2002 for review)
◦ Higher HbA1c found in those with ED (Rodin et al., 2002)
and therefore risks of these complications.
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T1D is most common chronic condition of childhood and adolescence (0.3-0.6%
by the age of 20; Karvonen et al., 2000)
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Mortality AN 0% – 15% depending on follow up period
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Crude mortality: 5% AN, 3.9% BN, 5.2% EDNOS (Steinhausen et al., 2002)
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In type 1 diabetes physical risks are far higher and therefore risk of death is also
much higher.
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Despite this staggering figure research has shown that adequate treatment can
prevent severe vision loss in 90% of cases of diabetic retinopathy Diabetic
Retinopathy Costs: Mean Average: £381,896.83 (70 PCTs) Median: £96,657
Diabetic Neuropathy Costs: Mean Average: £247,964.67 (60 PCTs) Median:
£28,385
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Binge / Purge types most prevalent in T1D
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NICE CG15:
1.4.3.1Diabetes care teams should be aware that children and young
people with type 1 diabetes, in particular young women, have an increased
risk of eating disorders.
1.4.3.2Diabetes care teams should be aware that children and young
people with type 1 diabetes who have eating disorders may have
associated problems of persistent hyperglycaemia, recurrent
hypoglycaemia and/or symptoms associated with gastric paresis.
1.4.3.3Children and young people with type 1 diabetes in whom eating
disorders are identified by their diabetes care team should be offered joint
management involving their diabetes care team and child mental
health professionals.
NICE CG9:
1.1.4.2 Treatment of both subthreshold and clinical cases of an eating
disorder in people with diabetes is essential because of the greatly
increased physical risk in this group.
1.1.4.3. People with type 1 diabetes and an eating disorder should have
intensive regular physical monitoring because they are at high risk of
retinopathy and other complications.
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Very useful to monitor physical health – used
routinely at each appointment with addition info
such as HbA1c, Ketones, hypos, insulin use.
Common language for mental health and
paediatrics.
Use proforma sheets to fill in each week and see
progress/ deterioration.
Weight loss
Disordered eating
weight
temp
Mental state
pulse
Activity
exercise
Risk
Purging
BP
Self harm
suicide
Squat test
Hydration Status
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Diabetics with Eating Disorders (Janet Treasure) DWED – updates to NICE 2017
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http://www.dwed.org.uk/
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A person with type 1 diabetes who has an eating disorder, particularly insulin omission,
cannot be dealt with in isolation by an eating disorder team. What DWED has observed to
be effective is the patients’ DSNs being proactive in collaborating with both the individuals
and their eating disorder teams to guide and educate them as to how diabetes can be
managed whilst the eating disorder is being treated. A multidisciplinary approach is the
only effective way to treat a person with type 1 diabetes and an eating disorder.
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“It doesn’t matter if a type 1 who omits insulin is 15 stone or 7 stone in DKA the risk
is the same and somebody somewhere has to start protecting us regardless of out
weight.” Allan & Nash (2015)
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DSM
Insulin omission may be viewed as a form of purging within the bulimia framework. In its
most recent incarnation, the DSM V (May 2013) Insulin omission is included as a clinical
feature of both Anorexia and Bulimia, in the clinical features of Anorexia the following is
written ‘Individuals with anorexia nervosa may misuse medications, such as by
manipulating dosage, in order to achieve weight loss or avoid weight gain. Individuals with
diabetes mellitus may omit or reduce insulin doses in order to minimize carbohydrate
metabolism’ (p376)
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https://www.diabeteswa.com.au
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Recurrent episodes of DKA/ Hyperglycaemia
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Recurrent episodes of Hypoglycaemia
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High HbA1c
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Frequent hospitalisations for poor blood sugar control
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Delay in puberty or sexual maturation or irregular
menses / amenorrhea
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Frequent trips to the Toilet
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Frequent episodes of thrush/ urine infections
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Nausea and Stomach Cramps
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Loss of appetite/ Eating More and Losing Weight
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Drinking an abnormal amount of fluids
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Hair loss Delayed Healing from infections/ bruises.
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Easy Bruising
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Dehydration – Dry Skin
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Dental Problems
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Blurred Vision
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Severe Fluctuations in weight/
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Severe weight loss/Rapid weight Gain/Anorexic BMI
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Fractures/ Bone Weakness
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Anaemia and other deficiencies
Early onset of Diabetic Complications particularly
neuropathy, retinopathy, gastroperisis & nephropathy
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Co – occurrence of depression, anxiety or other
psychological disturbance i.e. Borderline Personality
Disorder.
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Anxiety/ distress over being weighed at appointments
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Frequent Requests to switch meal plans
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Fear of hypoglycaemia
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Fear of injecting/ Extreme distress at injecting
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Continually requesting new meters (for the b.s.
Solution)
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Injecting in private
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Insisting on having injected out of view
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Avoidance of Diabetes Related Health Appointments
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Lack of BS testing /Reluctance to test
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Over/ under - treating Hypoglycaemic episodes
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A fundamental belief that insulin makes you fat
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Assigning moral qualities to food (i.e. good for sugars/
bad for sugars)
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An encyclopaedic knowledge of the carbohydrate
content of foods
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Persistent requests for weight loss medications
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If T1 is concurrent with hypothyroidism – abuse of
levothyroxine
Goebel-Fabbri et al.,
2009. Outpatient
management of eating
disorders in Type 1
diabetes. Diabetes
Spectrum, 22(3).
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Marathon not a sprint
• Diagnosis important for prognosis
• Important to “break bad news well” - families need to
be aware of the potential struggles ahead and to find
their own support.
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Steinhausen (1995) found that 43% of non
diabetic people recover completely, 36%
improve, 20% develop a chronic eating
disorder and 5% die from anorexia nervosa.
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Young person
Family
Peers
Diabetes Team / Paediatrics
CAMHS Team
Possibly Inpatient CAMHS
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15 years old
Pakistani cultural background
High pressure academically
Type 1 diabetes since 12 years old
Presenting with extremely high HBa1C, diabetes team
put immense amount of support with no changes
Weight initially 102% WFH
DKA admissions
Weight rollercoaster
Sub-clinical
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Referral to Diabetes Psychologist/ CAMHS
ASSESSMENT:
◦ Clues to distorted body image
◦ Clues to purging behaviours
◦ Motivational stage to changing diabetes related
behaviours... Fears
◦ Diabetes behaviours – looked as if doing injection, but
actually squirting insulin to the side.
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TREATMENT
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Ideas, what might you think about in terms of treatment?
What to consider?
How to involve family (especially with insulin)
What might implications be to your service for a patient
such as Rashida? – Would they be accepted to CAMHS?
Would they meet threshold? Who would see them?
◦ How might you overcome or would you change your
practice given what you know now?
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15 years old
Previous contact with Psychologist 2007 with
anxiety symptoms (slightly obsessive compulsive
in nature). Responded well to CBT approach.
Re-referred as urgent due to emergency
admission to Paeds ward; dizzy, weak. Rapid
deterioration in eating over last 6 months, notable
increase in HbA1C >13% (>120 mmol/mol).
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Restriction in food intake, initially down to 1200
KCals, then rapidly to nothing. Slow eater,
separating foods on plate. Drinking diet coke
excessively, hiding food in bathroom, hoarding
food in room, weighing self in room. Aggressive if
challenged to eat. No longer CHO counting. ?
Restricting insulin. Refusing to take snack if hypo.
76% WFH
HbA1c had risen significantly over last 6 months
(>85mmol/l).
Rapid loss of weight (also noticeable in lanugo
hair, emaciated appearance)
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Immediate (that day) MDT approach taken –
diabetes team, nursing, dietitian and psychology
initially and then psychiatry.
Investigations and full physical assessment
following Junior MARSIPAN guidelines (2012)
Low threshold for coeliac screening
Reduction of risk of re-feeding syndrome
Intensive psychological and physical monitoring
Followed family based model (FBT-type)
Weekly meetings between paediatric and
CAMHS team members.
Full MH assessment to examine co-morbidities
and subsequent treatment
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Seen on weekly basis initially. Overall 35 appointments
with Psychology (>10 joint with colleagues).1-2 hours
each session
Co-morbid diagnosis of OCD – well treated with
Sertraline 100mgs od
Psychological and Family interventions with regular
physical monitoring. Re-coaching of CHO counting and
insulin reviews.
Last weight was 61kg, BMI 19.8, 97% WFH which had
remained stable for some months
HbA1c 10% (86 mmol/mol) but not due to insulin
purposeful omission, rather due to lack of testing
He left to go to Oxford University to study Maths
recent updates say he is doing very well!
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I’d like to acknowledge the support of the Tayside
Diabetes Service in the Young and NHS Tayside
CAMHS Eating Disorders Team.
Any questions please email:
vicki.dunbar@nhs.net