RESEARCH ARTICLE
Eating Disorders in Individuals with Type 1 Diabetes: Case Series and day Hospital Treatment Outcome Patricia Anne Colton1*, Marion Patricia Olmsted2, Harmonie Wong3 & Gary Michael Rodin3 1
Eating Disorder Program, University Health Network, and Department of Psychiatry, University of Toronto, Canada Research Associate, Eating Disorder Program, University Health Network, Toronto, Canada 3 Psychosocial Oncology and Palliative Care, University Health Network, and Shirley Lederman Professor of Psychiatry, University of Toronto, Canada 2
Abstract Women with type 1 diabetes are at high risk for eating disorders (ED), a combination that can increase medical complications and mortality. As little is known about treatment response in this population, clinical presentation and treatment outcome in an extended case series were assessed. A chart review at the Eating Disorders Day Hospital Program at Toronto General Hospital identified a total of 100 individuals with type 1 diabetes assessed 1990–2012. Of 37 who attended day hospital, most experienced improvement in ED symptoms, but only 18.8% had a good immediate treatment outcome, while 43.8% had an intermediate outcome and 37.5% had a poor outcome (meeting diagnostic criteria at discharge). This is poorer than program outcomes in individuals without diabetes (χ 2 = 12.2, df = 2; p = 0.002). Factors influencing treatment engagement and outcome must be further studied and used to improve treatment results in this high-risk group. Copyright © 2015 John Wiley & Sons, Ltd and Eating Disorders Association. Received 18 November 2014; Revised 18 February 2015; Accepted 18 April 2015 Keywords eating disorder; diabetes; insulin omission *Correspondence Dr. Patricia Colton, Department of Psychiatry, University Health Network, 200 Elizabeth Street, 7 Eaton, Room 409, Toronto, ON, M5G 2C4 Canada. Tel: 416-3403477; Fax 416-340-3430. Email: [email protected] This research was carried out at the address of the corresponding author. Published online in Wiley Online Library (wileyonlinelibrary.com) DOI: 10.1002/erv.2365
Introduction Eating disorders (ED) are a common and serious mental health problem in individuals with type 1 diabetes. The frequency of these disorders in girls and women with type 1 diabetes is elevated compared with the general population, often at doubled or tripled rates (Colton, Rodin, Bergenstal and Parkin, 2009), and they frequently persist over years (Colton, Olmsted, Daneman, Rydall and Rodin, 2007; GoebelFabbri et al., 2011). ED confer an increased risk of diabetes-related medical complications (Goebel-Fabbri, 2009; Peveler et al., 2005); they are associated with poorer diabetes management and less stable blood sugar levels (Affenito et al., 1997a; Peveler et al., 2005), less favourable lipid profiles (Affenito et al., 1997b), an increased risk of retinopathy (Affenito et al., 1997b; Rydall, Rodin, Olmsted, Devenyi and Daneman, 1997), nephropathy (Takii et al., 2008) and neuropathy (Steel, Young, Lloyd and Clarke, 1987), and high mortality (Nielsen, 2002; Peveler et al., 2005). Although no research to date has clearly delineated the mechanisms that confer vulnerability to developing ED in those with type 1 diabetes, several diabetes-related factors have been postulated to contribute to this dangerous comorbidity. Type 1 diabetes management involves multiple daily blood-sugar checks, use of an 312
insulin pump or multiple daily insulin injections, and a high degree of attention to dietary intake and activity level. Although a diabetes meal plan is not generally calorie-restricted, the subjective restraint and attention to food can for some individuals resemble chronic dieting behaviour and dietary restraint, which are established risk factors for development of more disordered eating behaviour (Stice, 2002). Because of the metabolic properties of insulin therapy, individuals with type 1 diabetes are on average at a slightly higher weight than those without (Domargard et al., 1999). This may increase body dissatisfaction in vulnerable individuals and contribute to weight preoccupation and drive to lose weight. Family and personal dynamic issues related to control and autonomy may also be implicated and may reinforce the function of disordered eating behaviour in providing a sense of control and accomplishment. Finally, insulin underdosing or omission provides an easy though dangerous method for those with type 1 diabetes to rapidly lose weight. In this behaviour, the individual takes less insulin than is necessary for homeostasis. Blood glucose levels rise, and sugar and large amounts of water are lost in the urine. Insulin omission appears to be the central culprit in the increased morbidity and mortality seen in those with type 1 diabetes and ED. Insulin omission is common in
Eur. Eat. Disorders Rev. 23 (2015) 312–317 © 2015 John Wiley & Sons, Ltd and Eating Disorders Association.
P. A. Colton et al.
women with type 1 diabetes, often persists over time, and is associated with a tripled mortality rate (Goebel-Fabbri et al., 2008). Despite the development of evidence-based treatment guidelines for the management of ED (American Psychiatric Association, 2006), there has been little published regarding the efficacy of ED treatment in individuals with type 1 diabetes. A recent study comparing eating disorder treatment outcome in 20 individuals with type 1 diabetes and ED to a matched group without diabetes found higher dropout rates and worse treatment outcome in those with diabetes (Custal et al., 2014). A small study of outpatient cognitive-behaviour therapy for women with type 1 diabetes and ED suggested that ED may be more difficult to treat in those with type 1 diabetes than in those without (Peveler and Fairburn, 1992), although a small study of lengthy inpatient treatment of bulimia nervosa showed positive results (Takii et al., 2003). Two psycho-education studies failed to demonstrate behavioural or metabolic improvements in those with type 1 diabetes (Alloway, Toth and McCargar, 2001; Olmsted, Daneman, Rydall, Lawson and Rodin, 2002). It is possible that individuals with diabetes require more sustained or individualized interventions to support behavioural change, given that more complex behavioural change, involving all aspects of diabetes management, is required for stabilization and recovery. Overall, little is known about the response to specific ED treatment in those with type 1 diabetes. This leaves clinicians with little guidance to support employing existing treatment protocols in this high-risk group, or for making diabetes-specific treatment plan modifications. Toronto General Hospital (TGH) provides specialized ED consultation and day hospital treatment. Day hospitalization provides more structure and hours of treatment than most outpatient treatments, and is considered an appropriate and effective treatment modality for individuals with moderate to severe ED, and for those for whom less intensive outpatient treatment has not been helpful. It is associated with significant symptomatic improvement across settings (Fittig, Jacobi, Backmund, Gerlinghoff and Wittchen, 2008; Olmsted, McFarlane, Trottier and Rockert, 2013). Because intensive treatment is only provided to a few individuals with type 1 diabetes per year in this treatment setting, it has been difficult to assess effectiveness of this program in those with type 1 diabetes. This is a challenge shared by other ED programs, as programming specifically serving this population is rare. We have therefore undertaken a chart review study of consultations and day hospital admissions over a 22-year period in order to characterize the clinical presentation of individuals with type 1 diabetes seeking treatment at an academic ED treatment centre, and to assess the relative effectiveness of an intensive, cognitivebehavioural therapy (CBT)-based day hospital-treatment program for individuals with type 1 diabetes.
Eating Disorder Treatment Outcome in Diabetes
patient with type 1 diabetes. Approximately 6000 individuals overall were seen in consultation during the study period. Author P. C. trained and closely supervised the research assistant in this task. Assessment The following were collected by chart review and from an ongoing program database: 1. Eating disorder symptoms and diagnoses. Body mass index (BMI) and frequency of specific ED behavioural symptoms were collected for all individuals at consultation and, when applicable, at the beginning and at the end of day hospital treatment. ED behavioural frequencies were collected, and ED diagnoses generated using the Eating Disorder Examination diagnostic interview (Fairburn and Cooper, 1993), using DSM-IV criteria (Diagnostic and Statistical Manual of Mental Disorders, 4th Edition; American Psychiatric Association, 2000). In order to maximize reliability, interviewers in the clinic are provided with regular and ongoing supervision regarding use of the Eating Disorder Examination by an eating disorder specialist psychologist. Published diagnostic criteria for Eating Disorder Not Otherwise Specified (EDNOS) that our research team has longitudinally used in those with type 1 diabetes (Colton et al., 2007; Jones, Lawson, Daneman, Olmsted and Rodin, 2000) were employed for this study. 2. Diabetes management. Haemoglobin A1c (HbA1c) is a blood test that provides an estimate of blood sugar levels over the previous 2–3 months. Non-diabetic reference range is 4–6%, with a target range in those with type 1 diabetes
Eating Disorders in Individuals with Type 1 Diabetes: Case Series and day Hospital Treatment Outcome Patricia Anne Colton1*, Marion Patricia Olmsted2, Harmonie Wong3 & Gary Michael Rodin3 1
Eating Disorder Program, University Health Network, and Department of Psychiatry, University of Toronto, Canada Research Associate, Eating Disorder Program, University Health Network, Toronto, Canada 3 Psychosocial Oncology and Palliative Care, University Health Network, and Shirley Lederman Professor of Psychiatry, University of Toronto, Canada 2
Abstract Women with type 1 diabetes are at high risk for eating disorders (ED), a combination that can increase medical complications and mortality. As little is known about treatment response in this population, clinical presentation and treatment outcome in an extended case series were assessed. A chart review at the Eating Disorders Day Hospital Program at Toronto General Hospital identified a total of 100 individuals with type 1 diabetes assessed 1990–2012. Of 37 who attended day hospital, most experienced improvement in ED symptoms, but only 18.8% had a good immediate treatment outcome, while 43.8% had an intermediate outcome and 37.5% had a poor outcome (meeting diagnostic criteria at discharge). This is poorer than program outcomes in individuals without diabetes (χ 2 = 12.2, df = 2; p = 0.002). Factors influencing treatment engagement and outcome must be further studied and used to improve treatment results in this high-risk group. Copyright © 2015 John Wiley & Sons, Ltd and Eating Disorders Association. Received 18 November 2014; Revised 18 February 2015; Accepted 18 April 2015 Keywords eating disorder; diabetes; insulin omission *Correspondence Dr. Patricia Colton, Department of Psychiatry, University Health Network, 200 Elizabeth Street, 7 Eaton, Room 409, Toronto, ON, M5G 2C4 Canada. Tel: 416-3403477; Fax 416-340-3430. Email: [email protected] This research was carried out at the address of the corresponding author. Published online in Wiley Online Library (wileyonlinelibrary.com) DOI: 10.1002/erv.2365
Introduction Eating disorders (ED) are a common and serious mental health problem in individuals with type 1 diabetes. The frequency of these disorders in girls and women with type 1 diabetes is elevated compared with the general population, often at doubled or tripled rates (Colton, Rodin, Bergenstal and Parkin, 2009), and they frequently persist over years (Colton, Olmsted, Daneman, Rydall and Rodin, 2007; GoebelFabbri et al., 2011). ED confer an increased risk of diabetes-related medical complications (Goebel-Fabbri, 2009; Peveler et al., 2005); they are associated with poorer diabetes management and less stable blood sugar levels (Affenito et al., 1997a; Peveler et al., 2005), less favourable lipid profiles (Affenito et al., 1997b), an increased risk of retinopathy (Affenito et al., 1997b; Rydall, Rodin, Olmsted, Devenyi and Daneman, 1997), nephropathy (Takii et al., 2008) and neuropathy (Steel, Young, Lloyd and Clarke, 1987), and high mortality (Nielsen, 2002; Peveler et al., 2005). Although no research to date has clearly delineated the mechanisms that confer vulnerability to developing ED in those with type 1 diabetes, several diabetes-related factors have been postulated to contribute to this dangerous comorbidity. Type 1 diabetes management involves multiple daily blood-sugar checks, use of an 312
insulin pump or multiple daily insulin injections, and a high degree of attention to dietary intake and activity level. Although a diabetes meal plan is not generally calorie-restricted, the subjective restraint and attention to food can for some individuals resemble chronic dieting behaviour and dietary restraint, which are established risk factors for development of more disordered eating behaviour (Stice, 2002). Because of the metabolic properties of insulin therapy, individuals with type 1 diabetes are on average at a slightly higher weight than those without (Domargard et al., 1999). This may increase body dissatisfaction in vulnerable individuals and contribute to weight preoccupation and drive to lose weight. Family and personal dynamic issues related to control and autonomy may also be implicated and may reinforce the function of disordered eating behaviour in providing a sense of control and accomplishment. Finally, insulin underdosing or omission provides an easy though dangerous method for those with type 1 diabetes to rapidly lose weight. In this behaviour, the individual takes less insulin than is necessary for homeostasis. Blood glucose levels rise, and sugar and large amounts of water are lost in the urine. Insulin omission appears to be the central culprit in the increased morbidity and mortality seen in those with type 1 diabetes and ED. Insulin omission is common in
Eur. Eat. Disorders Rev. 23 (2015) 312–317 © 2015 John Wiley & Sons, Ltd and Eating Disorders Association.
P. A. Colton et al.
women with type 1 diabetes, often persists over time, and is associated with a tripled mortality rate (Goebel-Fabbri et al., 2008). Despite the development of evidence-based treatment guidelines for the management of ED (American Psychiatric Association, 2006), there has been little published regarding the efficacy of ED treatment in individuals with type 1 diabetes. A recent study comparing eating disorder treatment outcome in 20 individuals with type 1 diabetes and ED to a matched group without diabetes found higher dropout rates and worse treatment outcome in those with diabetes (Custal et al., 2014). A small study of outpatient cognitive-behaviour therapy for women with type 1 diabetes and ED suggested that ED may be more difficult to treat in those with type 1 diabetes than in those without (Peveler and Fairburn, 1992), although a small study of lengthy inpatient treatment of bulimia nervosa showed positive results (Takii et al., 2003). Two psycho-education studies failed to demonstrate behavioural or metabolic improvements in those with type 1 diabetes (Alloway, Toth and McCargar, 2001; Olmsted, Daneman, Rydall, Lawson and Rodin, 2002). It is possible that individuals with diabetes require more sustained or individualized interventions to support behavioural change, given that more complex behavioural change, involving all aspects of diabetes management, is required for stabilization and recovery. Overall, little is known about the response to specific ED treatment in those with type 1 diabetes. This leaves clinicians with little guidance to support employing existing treatment protocols in this high-risk group, or for making diabetes-specific treatment plan modifications. Toronto General Hospital (TGH) provides specialized ED consultation and day hospital treatment. Day hospitalization provides more structure and hours of treatment than most outpatient treatments, and is considered an appropriate and effective treatment modality for individuals with moderate to severe ED, and for those for whom less intensive outpatient treatment has not been helpful. It is associated with significant symptomatic improvement across settings (Fittig, Jacobi, Backmund, Gerlinghoff and Wittchen, 2008; Olmsted, McFarlane, Trottier and Rockert, 2013). Because intensive treatment is only provided to a few individuals with type 1 diabetes per year in this treatment setting, it has been difficult to assess effectiveness of this program in those with type 1 diabetes. This is a challenge shared by other ED programs, as programming specifically serving this population is rare. We have therefore undertaken a chart review study of consultations and day hospital admissions over a 22-year period in order to characterize the clinical presentation of individuals with type 1 diabetes seeking treatment at an academic ED treatment centre, and to assess the relative effectiveness of an intensive, cognitivebehavioural therapy (CBT)-based day hospital-treatment program for individuals with type 1 diabetes.
Eating Disorder Treatment Outcome in Diabetes
patient with type 1 diabetes. Approximately 6000 individuals overall were seen in consultation during the study period. Author P. C. trained and closely supervised the research assistant in this task. Assessment The following were collected by chart review and from an ongoing program database: 1. Eating disorder symptoms and diagnoses. Body mass index (BMI) and frequency of specific ED behavioural symptoms were collected for all individuals at consultation and, when applicable, at the beginning and at the end of day hospital treatment. ED behavioural frequencies were collected, and ED diagnoses generated using the Eating Disorder Examination diagnostic interview (Fairburn and Cooper, 1993), using DSM-IV criteria (Diagnostic and Statistical Manual of Mental Disorders, 4th Edition; American Psychiatric Association, 2000). In order to maximize reliability, interviewers in the clinic are provided with regular and ongoing supervision regarding use of the Eating Disorder Examination by an eating disorder specialist psychologist. Published diagnostic criteria for Eating Disorder Not Otherwise Specified (EDNOS) that our research team has longitudinally used in those with type 1 diabetes (Colton et al., 2007; Jones, Lawson, Daneman, Olmsted and Rodin, 2000) were employed for this study. 2. Diabetes management. Haemoglobin A1c (HbA1c) is a blood test that provides an estimate of blood sugar levels over the previous 2–3 months. Non-diabetic reference range is 4–6%, with a target range in those with type 1 diabetes
