**10. Prevention**

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

Psychotherapy individual, group, and family therapy are the most common ways to treat ED. There are no studies showing the best psychotherapy modality for patients with type 1 diabetes and ED or DEB. Some authors propose individual therapy to help patients to recover from ED and diabetes mismanagement (Krokoff, 1991). Adolescents with type 1 diabetes often struggle with emotional issues related to having the illness and use an ED as a maladaptive coping mechanism. Individual therapy can help patients to develop more healthy coping strategies. Often families of patients with diabetes and ED have not adequately coped with the feelings of grief related to having a chronic illness in the family and thus they have not adequately supported the patient with diabetes. Dysfuntional family dynamics can exacerbate difficulties of adjusting to the illness and of resolving issues of grief and loss associated with the diagnosis. Family therapy is recommended to help the family in developing more functional ways of relating and in addressing issues of grief and

Psychoeducation is a useful method to aid the patient to develop skills that will help him or her to cope with a chronic disease. Therefore, it can be helpful in type 1 diabetic patients

Psycho-pharmaceutical agents may be useful to treat comorbid mental health problems

One uncontrolled study of cognitive behavior therapy (Peveler & Fairburn, 1992) and several case reports of other treatment approaches for ED associated with type1 diabetes have been reported (Nielsen et al, 1987; Peveler & Fairburn, 1989; Ramirez et al, 1990). Further research is needed to demonstrate whether more intensive, prolonged or alternative interventions may have a more significant impact on metabolic control and other diabetes-

Avoid intensive glucose monitoring

 Avoid excessive attention to the foods Meal planning based on family customs

 Use insulin analog with better weight gain profile Measure body weight with bioimpedance devices Involve family member in metabolic control

 Individual or group psychotherapy promote self-esteem Individual psychotherapy to promote adequate coping

**Components Recommendations** 

Psychoeducation

Table 2. Components for the treatment of type 1 diabetic patients with ED or DEB.

Pharmacotherapy Drugs to treat comorbidities associated with ED or DEB: depression, anxiety, etc.

Diabetes therapy Avoid intensive insulin regimens

Nutrition Less rigid diet recommendations

Psychotherapy Family therapy

**9.3 Psychological therapy** 

loss that may be contributing to ED symptoms.

who have difficulties accepting the disease.

(Rosen, 2003). Table 2.

related outcomes.

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 until appropriate treatment begins for the concurrent ED.

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 diabetes self-management and to achieve better diabetes outcomes.

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 all family members involved in diabetes care.

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 treatment, especially in young women.

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 of ketoacidosis and/or weight and shape concerns.

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

Inadequate Coping Attitudes, Disordered Eating

health professionals are waiting.

**12. References** 

18, pp. 943-949.

pp. 309-315.

Vol. 11, pp. 279-309.

Behaviours and Eating Disorders in Type 1 Diabetic Patients 111

it is needed familiar therapy. Results of the treatment of these entities from experienced

The key for the management of type 1 diabetic patients with ED or DEB is the early diagnosis and treatment. Unfortunately, validated questionnaires to screen type 1 diabetic population are not available so far. Therefore it is important that the staff of the diabetes team who treats these patients should know the relationship between poor diabetes metabolic control and intentional misuse of insulin, or the recommended diet to control weight gain. They also should know that strict diet and intensive insulin regimens are risk factors for the development of DEB or ED. Therefore, it would be important to be alert to detect excessive concern about body weight, shape or body dissatisfaction in these patients. Eating disorders in type 1 diabetic patients represent some of the most complex patient problems to treat both medically and psychologically. Given the extent of the problem and the severe medical risk associated with it, more clinical and technological research aimed to

Abrams, KK., Allen, L., & Gray, JJ. (1993). Disordered eating attitudes and behaviors,

Affenito, SG., Backstrand, JR., Welch, GW., Lammi-Keefe, CJ., Rodriguez, NR., & Adams,

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elevations in HbA1c values, repeated problems with diabetic ketoacidosis and amenorrhea (Olmsted et al, 2008). Recently, Markowitz et al. (Markowitz et al, 2010) proposed a 16-items diabetes-specific self-reported measure of disordered eating for brief screening tool for disordered eating in diabetes. Table 3.

Individual or group intervention aimed to increase self-esteem, appearance and body acceptance, and family-based interventions with the objective of developing flexible approaches to food and meal planning may help to avoid the development of DEBs in type 1 diabetic patients.


Table 3. Clues to early diagnose ED or DEB in type 1 diabetics
