**9. The management of eating behavioral anomalies in type 1 diabetics**

No treatment outcome studies to date have examined treatment efficacy for DEB and ED in type1 diabetics, for this reason, many of the recommendations have not yet been empirically evaluated. ED have been shown to convey their own significant medical risk and also appear to persist and worsen over time. Treatment aimed at promoting family comanagement of diabetes treatment tasks and decreasing diabetes-related family conflict have already been shown to promote improved diabetes outcomes in children and teens with type 1 diabetes (Nansel et al, 2008).

Despite the fact that little research has been done to determine the best treatment approaches for the problem of type 1 diabetic patients with ED or DEB, a multidisciplinary care team is considered the standard to treat these people. Such a team should include an endocrinologist/diabetologist, a nurse educator, a nutritionist with ED and/or diabetes training and a psychologist or social worker to provide weekly therapy. Depending on the severity of related psychiatric symptoms, such as depression and anxiety, a psychiatrist for psychopharmacologic evaluation and treatment should also be consulted. Team members must be allowed to frequently an openly communicate with each other to maintain congruent treatment approaches, messages and goals. Patients may require a medical or psychiatric inpatients hospitalization until they are medically stable and emotionally ready to engage in treatment as outpatients. Early in the treatment, monthly appointments with a team endocrinologist or nurse educator may be necessary to maintain medical stability, and monthly appointments with the nutritionists are also recommended. Laboratory tests, especially HbA1c and electrolytes, and weight checks should occur routinely at medical appointments. Unfortunately, such specialty services are rarely available to individuals with diabetes.

As a result, detection of insulin restriction may be unlikely until after the problem has become habitual and entrenched. Goebel-Fabbri et al (Goebel-Fabbri 2008) suggest that insulin restriction can be captured by a single screening item "I take less insulin than I should". The use of this question in routine clinical practice has the potential to identify atrisk subjects and, consequently, to make possible an early intervention. However, further studies are needed to assess the clinical utility of adopting such a question as a screening tool to identify insulin restrictors.

The overall goal of the treatment of patients with type 1 diabetes and DEB and ED is to return the patients to a state of premorbid physical and mental health. Treatment begins with emphasis on nutritional rehabilitation, weight restoration and adequate diabetes control (Anzai et al, 2002; Krakoff, 1991).

Psychotherapy should begin immediately for the patient and family, but it is not effective for the patient when is in a starvation mode (Walsh et al, 2000).

#### **9.1 Diabetes treatment**

106 Type 1 Diabetes – Complications, Pathogenesis, and Alternative Treatments

from the 12- to 24-month period. The results suggested the value of parent-adolescent

The results of the mentioned studies of coping skills training and problem-solving interventions in children, and adolescents with diabetes, as well as parents of children with diabetes, have demonstrated that these interventions are effective in assisting people to improve diabetes self management and to achieve better diabetes outcomes (Grey &

No treatment outcome studies to date have examined treatment efficacy for DEB and ED in type1 diabetics, for this reason, many of the recommendations have not yet been empirically evaluated. ED have been shown to convey their own significant medical risk and also appear to persist and worsen over time. Treatment aimed at promoting family comanagement of diabetes treatment tasks and decreasing diabetes-related family conflict have already been shown to promote improved diabetes outcomes in children and teens

Despite the fact that little research has been done to determine the best treatment approaches for the problem of type 1 diabetic patients with ED or DEB, a multidisciplinary care team is considered the standard to treat these people. Such a team should include an endocrinologist/diabetologist, a nurse educator, a nutritionist with ED and/or diabetes training and a psychologist or social worker to provide weekly therapy. Depending on the severity of related psychiatric symptoms, such as depression and anxiety, a psychiatrist for psychopharmacologic evaluation and treatment should also be consulted. Team members must be allowed to frequently an openly communicate with each other to maintain congruent treatment approaches, messages and goals. Patients may require a medical or psychiatric inpatients hospitalization until they are medically stable and emotionally ready to engage in treatment as outpatients. Early in the treatment, monthly appointments with a team endocrinologist or nurse educator may be necessary to maintain medical stability, and monthly appointments with the nutritionists are also recommended. Laboratory tests, especially HbA1c and electrolytes, and weight checks should occur routinely at medical appointments. Unfortunately, such specialty services

As a result, detection of insulin restriction may be unlikely until after the problem has become habitual and entrenched. Goebel-Fabbri et al (Goebel-Fabbri 2008) suggest that insulin restriction can be captured by a single screening item "I take less insulin than I should". The use of this question in routine clinical practice has the potential to identify atrisk subjects and, consequently, to make possible an early intervention. However, further studies are needed to assess the clinical utility of adopting such a question as a screening

The overall goal of the treatment of patients with type 1 diabetes and DEB and ED is to return the patients to a state of premorbid physical and mental health. Treatment begins with emphasis on nutritional rehabilitation, weight restoration and adequate diabetes

Psychotherapy should begin immediately for the patient and family, but it is not effective

**9. The management of eating behavioral anomalies in type 1 diabetics** 

partnership in diabetes management.

with type 1 diabetes (Nansel et al, 2008).

are rarely available to individuals with diabetes.

tool to identify insulin restrictors.

control (Anzai et al, 2002; Krakoff, 1991).

for the patient when is in a starvation mode (Walsh et al, 2000).

Berry, 2004).

The diabetes team has the important responsibility of monitoring insulin regimens and providing education about diabetes management and potential complications to patients and families (Krakoff, 1991). There are no studies looking at treatment of ED/DEB in youth with type 1 diabetes. The traditional approaches to poor blood glucose control involving a stricter and more intensive monitoring of the diabetic management may increase the risk for disordered eating (Colton et al, 1999). For this reason, it is recommended a less rigid approach in the insulin regimen and nutrition therapy to improve DEB. Lowering the amount of time spent on diabetes management during the day may help to lessen stress associated with the diabetes, which may in turn help alleviate DEB. Krokoff (Krokoff, 1991) suggested that self-destructive insulin manipulation within the context of an ED may also be an indirect call for help, signaling the need for more parental/adult intervention in patient's physical and mental health.

Trento et al, (Trento et al, 2009) suggest that offering a carbohydrate counting program within a group care management approach may help patients with type 1 diabetes acquire better self-efficacy and restructure their cognitive and lifestyle potential.

Technological advances can also be used to address specific treatment issues seen in these patients. For example, the first challenge that most patients face is weight gain associated with insulin restart. Patients need to be taught to indentify insulin edema, which may make them feel fat, bloated and uncomfortable, as temporary water retention that is different from the development of fatty tissue. Special tools designed to measure water-related weight versus lean muscle mass versus fat mass could help patients tolerate the temporary weight gain related to edema (Goebel-Fabbri 2008). Additionally, newer insulin analogs show evidence of improving weight profiles which could be of help (Goebel-Fabbri 2008; Russell-Jones & Khan, 2007).

#### **9.2 Nutritional management**

The dietician must balance the difficult tasks of providing diabetes education, ED education, writing meal plans and defining weight goals for patients and families (Anzai et al, 2002; Krakoff, 1991). The challenge presents when trying to balance the goal of slow weight gain and /or maintenance with diabetes meal planning. As the patient continues to increase calorie intake, insulin doses will need to be adjusted to match the amount of food eaten avoiding hyperglycemia. It is recommend a realistic goal of good blood glucose control instead of optimal blood glucose levels as the body readjusts to refeeding and the patient begins to benefit from psychotherapy. Multiple daily injections regimens that use insulin to carbohydrate ratios provide greater flexibility with meal times and amounts of food but do require increased blood glucose monitoring and insulin injections. Such intense diabetes management may increase the potential for disordered eating as the child or adolescent must think constantly about the effects of food, insulin and exercise on his or her blood glucose levels. This may not be an ideal approach to diabetes meal planning during the treatment and recovery from the ED. As the individual's physical and psychological health improves, the incorporation of more flexible meal-planning strategies may be useful. Care professionals, including nutrition therapists and diabetes educators, should be sensitive to weight-related changes and concerns in youth with type 1 diabetes. It is important for all health care professionals to be aware that weight loss may be related to glycaemia control.

Inadequate Coping Attitudes, Disordered Eating

until appropriate treatment begins for the concurrent ED.

all family members involved in diabetes care.

treatment, especially in young women.

of ketoacidosis and/or weight and shape concerns.

diabetes self-management and to achieve better diabetes outcomes.

**10. Prevention** 

Behaviours and Eating Disorders in Type 1 Diabetic Patients 109

Since most type 1 diabetic patients do not admit to having an ED, this condition is commonly detected first by health care professionals (Walsh et al, 2000). The diabetes team may be the first to discover an ED and can play a crucial role in recommending proper treatment to the patient and family. It is unlikely that diabetes management will improve

The results of studies on coping skills training and problem-solving interventions in children, adolescents, and adults with diabetes, as well as parents of children with diabetes, have demonstrated that these interventions are effective assisting people to improve

In childhood, the data suggest that interventions should include both children or adolescents and their parents within the first years after the diagnosis to improve selfmanagement through learning problem-solving skills. Health care providers need to pay particular attention to adolescents with poorer glycaemia control and quality of life when they intensify their treatment, because they are less likely to reach treatment goals and may require additional support. Serious problems with self-management usually emerge during early adolescence and are difficult to correct [41,42]. The family management of diabetes should include a cooperative relationship between the patient, his or her family, and the diabetes health care provider team. The complexities of diabetes care demand a multifaceted approach that includes a strong foundation of diabetes education, medical supervision, reinforcement of positive self-care behaviors, and behavioral interventions that include problem solving and coping skills training. It is imperative to use problem solving strategies with psychological support that meet the developmental stage and level of adjustment for

Clinic-based group interventions for young women with diabetes and DEB may be the most practical and nonstigmatizing approach to prevention and early intervention for this problem. Rigid approaches to the dietary management of diabetes can contribute to the development of DEB. Rigid dieting has been shown to be a risk factor for ED in nonobese, nondiabetic women (Stewart et al, 2002). In type 1 diabetic patients feelings of deprivation associated with the perceived requirement for dietary restraint may trigger episodes of binge eating and subsequent insulin omission to prevent weight gain. Further, the weight gain associated with intensive diabetes management may amplify body dissatisfaction and the drive for thinness in susceptible girls (Daneman et al, 1998; Daneman & Rodin, 1999). For these reasons less intensive regimens are recommended in the initial stage of diabetes

It is recommended that the health care professional who treat young women with type 1 diabetes maintain a high index of suspicion for the presence of an eating disturbance, particularly among those patients with persistent poor metabolic control, repeated episodes

Screening for disordered eating behaviors in type 1 diabetics would be the best approach to get an early detection of behavioral abnormalities in these patients, however, a validated screening tool is not available yet (Dion Kelly et al, 2005). Clinicians working with adolescent and young adult women diabetes should be cognizant of patterns that might indicate the presence of DEB in their patients. They can include extreme concerns about weight and body shape, unusual patterns of intense exercise, sometimes accompanied or followed by frequent hypoglycemia, unusually low-calorie meal plans, unexplained
