Eating disorders and insulin manipulation in children and young people with diabetes

John Gregory – Division of Population Medicine, School of Medicine, Cardiff University

Type 1 diabetes mellitus (T1DM) is a common chronic disease in children and young people. Living with diabetes can pose challenges both medical and psychological.

The management of T1DM includes a focus on healthy eating, carbohydrate counting and insulin timing. Young people are regularly weighed and their weight is openly discussed with often a noticeable increase in weight after diagnosis. This can lead to an over-focus on body weight and shape with negative implications for blood glucose control.

A number of studies have identified high rates of eating disorders, issues with body image and intentional manipulation of insulin for weight loss among young people with diabetes.  This is associated with increased risk of short-term and long-term health complications and death.

Consultation

• Focus is needed during the consultation to establish the underlying cause of the poor blood glucose control and weight loss which will shape subsequent management.
• There are many psychosocial issues that impact on blood glucose control. At times, young people struggle to engage with their diabetes, leading to reluctance to follow their insulin regime or monitoring of blood glucose. There are many reasons for this and it is important to explore home, school, friendship, activities and risk-taking behaviours to explore potential risks.

Management

• Early intervention is essential in the management of any eating disorder, but particularly in those with T1DM.
• Specific targeting of at-risk children with diabetes may prove beneficial.
• There is evidence that prevention programmes focused on positive body image and anti-restrictive behaviours significantly reduce the incidence of eating disorder development.
• Dietetic treatment should encourage flexible and non-restrictive approaches to eating, while still focusing on regular meal patterns and carbohydrate counting.
• Psychological therapy for eating disorders may take various forms depending on the individual and condition, for example, Cognitive Behavioural Therapy (CBT) and family therapy.
• Identifying eating disorders and diabulimia (insulin omission or manipulation) to induce weight loss can be difficult in practice. Raising awareness among multidisciplinary teams is crucial to ensure these problems are considered in consultations.
• Screening tools and surveys that identify eating disorders can be effective and should be used and considered as part of annual diabetes review.
• The management of eating disorders and diabetes is challenging and conventional approaches to diabetes care may need to be adapted to fit the individual.
• Effective joint working with mental health teams forms a key part of treatment and recovery with early liaison encouraged.