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Eating disorders: Under Dosing to Overeating

Eating disorders: Under Dosing to Overeating. Lea Crosetti , RD. Presenter Disclosure Information. In compliance with the accrediting board policies, the American Diabetes Association requires the following disclosure to the participants:. Name of Presenter: Lea Crosetti, RD.

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Eating disorders: Under Dosing to Overeating

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  1. Eating disorders: Under Dosing to Overeating Lea Crosetti, RD © Bariathletes ® 2011

  2. Presenter Disclosure Information In compliance with the accrediting board policies, theAmerican Diabetes Association requires the following disclosure to the participants: Name of Presenter: Lea Crosetti, RD Disclosed no conflict of interest © Bariathletes ® 2011

  3. Objectives Overall Objective: Describe common eating disorders and how they affect diabetes management. Specific Objectives: • Become familiar with the prevalence and growth of eating disorders among those with diabetes • Identify risk factors and warning signs • Learn of the complications and impact • Determine treatment strategies © Bariathletes ® 2011

  4. Disordered Eating Etiology • The etiology is multifactorial • Beyond food and weight loss • Much more research is needed • Gender and ethnicity, weight and shape, and genetics • Triggers • Food restriction • Fad diets, food scarcity, medical diets • Poor body image • Weight fluctuations, wanting to be thinner • Coping • Trauma © Bariathletes ® 2011 American Academy of Eating Disorders 2011

  5. Binge Cycle or Diet Cycle © Bariathletes ® 2011 Leahy, R. American Institute of Cognitive Therapy. 2011

  6. Are people with diabetes at a higher Risk of developing an eating disorder? • Earlier studies showed no significant increase in developing an eating disorder among those with diabetes • These studies used a small sample size with narrow age range • More recent studies with larger sample sizes and age ranges have showed that eating disorders are more common for those with diabetes • Women with type 1 diabetes are 2.4 times more at risk Jones JM, et al. BMJ.2000(320): 1563-1566 Goebel-Fabbri A. J Diabetes Sci Technol. 2008 May; 2(3): 530–532. Nielsen S. Eur Eat DisordRev 2002;10:241–254. © Bariathletes ® 2011

  7. Is Intensive Treatment the Problem? • Weight cycling with weight loss at onset and regain with insulin • Trend for higher BMI • Dietary restriction and the increased attention to food and exercise • Parallels the rigid thinking of women eating disorders • Diabetes Control and Complications Trial Research Group. Diabetes Care 1988;11:567-573. • Diabetes Control and Complications Trial Research Group. N Engl. J Med. 1993;(329);977-986 • Goebel-FabbriA, et al. Diabetes Care. 2008; 31(3):415-419 © Bariathletes ® 2011

  8. Prevalence Among Adolescent Females With and Without Diabetes • Adolescent females with diabetes were twice as likely as females without diabetes to develop an eating disorder • Insulin misuse was the most common weight loss practice after dieting for women with type 1 diabetes • With 42% (15 out of the 36) of diabetic subjects with an eating disorder using less insulin to control weight • Less dieting compared to control group due to ability to limit insulin and dietary restriction of diabetes management Jones JM, et al. BMJ.2000(320): 1563-1566 © Bariathletes ® 2011

  9. Diabulimia • Omission or reduction of insulin for the purpose of weight loss or maintenance • Calories are therefore “purged” through glucosuria • This compensatory behavior is one of the criteria for bulimia nervosa in DMS IV (Diagnostic and Statistical Manual of Mental Disorders) • However, it is not recognized as a medical diagnosis Huefeng-Shih, Grace 2011.Diabulimia . American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders. 4th Ed. Washington, DC, American Psychiatric Association, 2000. © Bariathletes ® 2011

  10. Prevalence of Diabulimia • On average about 31% type 1 women reported insulin restriction as means for weight loss. • Rates of insulin omission peaked in adolescent and early adulthood. AckardDM, et al. PediatrDiabetes 2008;9:312–319. Peveler RC, et al. Diabetes Care 2005;28:84–88. © Bariathletes ® 2011

  11. Eating Behaviors of Male and Females With Type 1 Diabetes Neumark-Sztainer, D. Diabetes Care. 2002;25:1289-1296 © Bariathletes ® 2011

  12. Unhealthy Eating Behaviors of Adolescent Type 1 and Type 2 Patients Lawrence J, et al. Diabetes Care 2002, December 31(12): 2251-2257 © Bariathletes ® 2011

  13. Eating disorders among Adults with Type 2 Diabetes • Increased risk of Binge Eating Disorder (BED) • Eating objectively large amounts of food with a perceived loss of control in a 2 hour period • Increased of Night Eating Syndrome (NES) • More than 25% of total daily intake occurs after the evening meal and/or there are at least 3 nocturnal awakenings to eat weekly Allison KC et al. Obesity. 2007;15(5): 1287-1293 American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders. 4th Ed. O’Reardon JP et al. Obes Res. 2004;12:1789-1796 © Bariathletes ® 2011

  14. Binge Eating disorder Among Adults with Type 2 Diabetes • 2%- 26% of those with type 2 diabetes have binge eating disorder • Women • Higher BMI • Increased depressed mood Crow s et al. Int J Eat Disord.2001;30:222-6 Mannucci E et al. Int J ObesRelatMetabDisord. 2002;26-848-53 © Bariathletes ® 2011

  15. Night Eating Syndrome among adults with type 2 diabetes • About 9.7% of population with type 2 diabetes have night eating syndrome • Lower adherence to diet, exercise and monitoring • Increased depressed mood • Increased risk of obesity, A1C >7%, and diabetes complications Morse SA et al. Diabetes Care. 2006;29”1800--4 © Bariathletes ® 2011

  16. Complications / Impact • Diabetes Control and Complication Trial (DCCT) and Epidemiology of Diabetes Interventions and Complications (EDIC) • Kidneys • Eyes • Nerves • Heart Diabetes Control and Complications Trial Research Group. Diabetes Care 1988;11:567-573. Diabetes Control and Complications Trial Research Group. N Engl. J Med. 1993;(329);977-986 © Bariathletes ® 2011

  17. Complications / Impact • Poor glycemic control • Microvascular complications • Increased infections • More frequent DKA • Increased retinopathy • Increase nephropathy and foot problems • More frequent hospitalization and ER visits • Younger age of mortality • Increased mortality • Jones JM, et al. BMJ.2000(320): 1563-1566 • Neumark-Sztainer D, et al. Diabetes Care 25:1289-1296, 2002 • Peveler RC, et al. Diabetes Care 2005;28:84–88. • Goebel-Fabbri A, et al. Diabetes Care. 2008; 31(3):415-419 © Bariathletes ® 2011

  18. Microvascular Complications • Peveler RC, et al. Diabetes Care 2005;28:84–88. © Bariathletes ® 2011

  19. Morbidity and Mortality in Women with Type 1 Diabetes • 11 year follow up study with women with type 1 diabetes • 234 women total • Mean age of 45 years and mean diabetes duration of 28 years • Goebel-Fabbri A, et al. Diabetes Care. 2008; 31(3):415-419 © Bariathletes ® 2011

  20. Complication Comparison Between Appropriate Insulin Users and Insulin Restrictors • Goebel-Fabbri A, et al. Diabetes Care. 2008; 31(3):415-419 © Bariathletes ® 2011

  21. Age at Death Comparison Between Appropriate Insulin Users and Insulin Restrictors • Goebel-Fabbri A, et al. Diabetes Care. 2008; 31(3):415-419 © Bariathletes ® 2011

  22. Mortality Rate of Those Who Reported “Always Taking Less Insulin” • Goebel-Fabbri A, et al. Diabetes Care. 2008; 31(3):415-419 © Bariathletes ® 2011

  23. Warning Signs • Female gender • Young age • High BMI • Elevated A1C • Perfect blood sugar recordings but high A1C • Forgetting to bring meter to appointment • Poor diabetes self-care • Heightened diabetes distress • Irregular menses or amenorrhea Goebel-Fabbri A, et al. Diabetes Care. 2008; 31(3):415-419 Markowitz JT et al. Diabet Med. 2009;26(11):1165-1171 Meltzer L, et al. Diabetes Care. 2001;24:678-682 Neumark-Sztainer, D. Diabetes Care. 2002;25:1289-1296 © Bariathletes ® 2011

  24. Warning Signs • More eating disordered and bulimia symptoms • Calorie obsession • Poor body image • Body checking • Drive for thinness • Unhealthy weight goals • Scale obsession • Low levels of family cohesion • Depression • Compulsive exercising Goebel-Fabbri A, et al. Diabetes Care. 2008; 31(3):415-419 Markowitz JT et al. Diabet Med. 2009;26(11):1165-1171 Meltzer L, et al. Diabetes Care. 2001;24:678-682 Neumark-Sztainer, D. Diabetes Care. 2002;25:1289-1296 © Bariathletes ® 2011

  25. Treatment • Multi-disciplinary team • Endocrinologist, psychologist/social worker, dietitian, diabetes educator, psychiatrist • Practitioners with experience with both diabetes and eating disorders Goebel-Fabbri A, et al. Diabetes Care. 2008; 31(3):415-419 Huefeng-Shih, Grace 2011.Diabulimia . \ © Bariathletes ® 2011

  26. Treatment • Endocrinologist • Monthly appointments • Lab and weight checks at each appointment • Psychotherapy • Weekly or bi-weekly appointments • Cognitive Behavior Therapy (CBT), Dialectical Behavioral Therapy (DBT), and Family Based Therapy (FBT) Goebel-Fabbri A, et al. Diabetes Care. 2008; 31(3):415-419 Huefeng-Shih, Grace 2011.Diabulimia . © Bariathletes ® 2011

  27. Treatment What doesn’t work What works Scare tactics Guilt trips Belittling Learn what motivates them Set small goals Help to develop healthy lifestyle Education Huefeng-Shih, Grace 2011.Diabulimia. © Bariathletes ® 2011

  28. Treat the disorder • Treat the binge eating disorder prior to weight loss • By focusing on weight loss may perpetuate the binge/diet cycle Gorin, AA et al. Arch Gen Psychiatry. 2008;65(12):1447-55 © Bariathletes ® 2011

  29. Knowing Your Population • Most want to recover but don’t see anyway out • They don’t like that their blood sugars are out of control (even if they act like they don’t care) • If they had a method to maintain their weight AND blood sugars levels they will do it • Dealing with the foggy, under-nourished thinker • Teenage education model • They want to know the “whys” • They want to feel understood • Personal stories © Bariathletes ® 2011

  30. To Weigh Or Not To Weigh… • Could add more stress and anxiety at appointments • Could keep focus on weight rather than behaviors • Some falsely think they gained • Good time to educate • Good/safe place to address weight • May likely be weighing themselves at home • Blind weights • Weight ranges © Bariathletes ® 2011 Huefeng-Shih, Grace 2011.Diabulimia.

  31. Identifying They Have A Problem • Have them identify with signs and symptoms of starvation • Physical, cognitive, psychosocial, behavioral • They don’t think they are starving themselves because they are eating • Educating that the body is starved © Bariathletes ® 2011

  32. Educate to Bring Food Back Into the Positive • Educate how active the body is and how calories provide that energy • Include exercise • Clearing up misconceptions and myths • Dangers of fad diets • Binge/Diet Cycle • Misconceptions about macronutrients • How to balance meals • How to incorporate carb counting © Bariathletes ® 2011

  33. Keeping it Positive • Avoid black and white thinking • No such thing as “bad” foods • Preventing binges/purges • Educate how all foods fit • Control vs manage • Helpful with goal setting and achieving • Foods vs supplements • Start with a supplement • MVI, Ca, Omega 3 • Educating on whole food benefits Wachter, A. Marcus M. Don’t Diet Live It Workbook. Healing Food, Weight and Body Issues. 1999. © Bariathletes ® 2011

  34. Intuitive Eating • Hunger/fullness and the body’s own internal signals • May be totally disconnected from dieting • Using a numerical scale to help identify signals • Interval eating may be needed at first • Eating every 3-5 hours • Helping with blood sugar and hunger levels © Bariathletes ® 2011 Craighead L. Appetite Awareness Workbook. 2006..

  35. Goal Setting • SMART: Small, measureable, achievable, reasonable, and time oriented goals • Focus on behaviors not weight • Have them acknowledge their efforts and have coping strategies • Reminding that recovery is not linear • Benefits of challenges and relapse as a learning possibility © Bariathletes ® 2011

  36. References • American Academy of Eating Disorders, 2011. “About Eating Disorders” • Leahy, R. American Institute of Cognitive Therapy. 2011. “Eating Disorders” • Jones JM, et al. Eating Disorders in Adolescent Females with and without type 1 diabetes. BMJ.2000(320): 1563-1566 • Goebel-FabbriA. Diabetes and Eating Disorders. J Diabetes Sci Technol. 2008 May; 2(3): 530–532. • Nielsen S. Eating disorders in females with type 1 diabetes: an update of a meta-analysis. Eur Eat Disord Rev 2002;10:241–254. • Diabetes control and Complications Trial (DCCT) Research Group. Weight gain associated with intensive therapy in the diabetes control and complications trial. Diabetes Care 1988;11:567-573. • The Diabetes Control and Complications Trial Research Group. The effect of intensive treatment of diabetes on the development and progress of long term complications in insulin dependent diabetes mellitus. The Diabetes Care and Complications Trial Research Group. N Engl. J Med. 1993;(329);977-986 • Goebel-Fabbri A, et al. Insulin restriction and associated morbidity and mortality in women with type 1 diabetes. Diabetes Care. 2008; 31(3):415-419 • Allison KC et al. Binge Eating Disorder an d Night Eating Syndrome in Adults with Type 2 Diabetes. Obesity. 2007;15(5): 1287-1293 • O’ReardonJP et al. Circadian Eating and Sleeping patterns in the Night Eating Syndrome. ObesRes. 2004;12:1789-1796 • American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders. 4th Ed. Washington, DC, American Psychiatric Association, 2000. • Crow s et al. Binge eating and other psychopathology in patients with type 2 diabetes mellitus. Int J Eat Disord.2001;30:222-6 • Mannucci E et al. Eating behavior in obese patietns with and without type 2 diabetes. Int J ObesRelatMetabDisord. 2002;26-848-53 © Bariathletes ® 2011

  37. References • Morse SA et al. Isn’t this just bedtime snacking? The potential adverse effects on night-eating symptoms on treatment adherence and outcomes in patience with diabetes. Diabetes Care. 2006;29:1800--4 • Neumark-Sztainer, D. Weight control practices and disordered eating behaviors among adolescent females and males with Type 1 Diabetes. Diabetes Care. 2002;25:1289-1296 • Huefeng-Shih, Grace 2011.Diabulimia . Published by Grace Huefen-Shih. • Gorin, AA et al. Binge eating and weight loss outcomes in overweight and obese individuals with type 2 diabetes. Arch Gen Psychiatry. 2008;65(12):1447-55 • Ackard DM, et al. Disordered eating and body dissatisfaction in adolescents with type 1 diabetes and a population-based comparison sample: comparative prevalence and clinical implications. Pediatr Diabetes 2008;9:312–319. • PevelerRC, et al. The relationship of disordered eating habits and attitudes to clinical outcomes in young adult females with type 1 diabetes. Diabetes Care 2005;28:84–88. • Lawrence J, et al. Weight loss Practices and Weight Related Issues Among Youth with Type 1 or Type 2 Diabetes. Diabetes Care 2002, December 31(12): 2251-2257 • Markowitz JT et al. Self reported history of overweight and its relationship to disordered eating in adolescent girls with type 1 diabetes. Diabet Med. 2009;26(11):1165-1171 • Meltzer L, et al. Disordered eating, body mass, and glycemic control in adolescents with type 1 diabetes. Diabetes Care. 2001;24:678-682 • Wachter, A. Marcus M. Don’t Diet Live It Workbook. Healing Food, Weight and Body Issues. 1999. GurzeBooks. • Craighead L. Appetite Awareness Workbook. 2006. New Harbinger Publications Inc. © Bariathletes ® 2011

  38. LeaCrosetti@BariAthletes.com www.BariAthletes.com 877-66-FUEL4YOU Questions? © Bariathletes ® 2011

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