Registered dietitians and nurses who specialize in diabetes education are often in the position of identifying patients at risk for an eating disorder or those who have an undiagnosed eating disorder. Diabetes educators will find it helpful to establish relationships and communication with eating disorder specialists in their area to prepare a plan for caring for these individuals.
Registered dietitians (RDs) and nurses specializing in diabetes are trained to assess patients' understanding of diabetes and their educational needs. The National Standards for Diabetes Self-Management Education include a standard that all patients with diabetes receive an individualized assessment, which includes, among other things, relevant medical history and health beliefs and attitudes assessment.1 It is appropriate for diabetes educators to evaluate for eating disorders as part of this assessment and to review patients' medical history for signs that might lead to an eating disorder diagnosis.
The functions of diabetes educators include helping individuals identify barriers to diabetes self-management, facilitating problem-solving and coping skills, and helping patients to balance eating, physical activity, medication, and blood glucose monitoring routines.2 While performing these tasks, diabetes educators may encounter patients with a diagnosed eating disorder, with an undiagnosed eating disorder, or at particular risk of developing an eating disorder. It is crucial that diabetes educators are alert to these possibilities. This article summarizes information about identifying patients with an eating disorder and establishing treatment teams.
Diabetes and Eating Disorders
It is important for diabetes educators to have a general understanding of eating disorders and diagnostic criteria to help identify patients with or at risk for developing them. (These criteria are discussed in detail in the article on p. 143 of this issue.) Table 1 presents risk factors and warning signs related to eating disorders in patients with type 1 diabetes (ED-DMT1) with which educators should be familiar.
Because diabetes educators seek to understand patients' day-to-day lifestyle activities, they are often the first health care professional to identify potential eating disorders. Patients rarely openly state that they have an eating disorder. Rather, the signs and symptoms are visible once the educator is alert to them and include increases in A1C levels, recurrent diabetes ketoacidosis (DKA), great interest in body shape and size, and over-exercising. Patients may comment about advanced physical symptoms such as hair loss or thinning, fainting episodes, or abdominal pain, or specific symptoms such as not eating with family or friends (anorexia), excusing themselves to the bathroom right after eating (bulimia), or frequently not having their insulin available at mealtime (insulin omission). These comments can easily be overlooked and not appropriately addressed unless educators are aware that they could be signs of an eating disorder.
Educators should be concerned about the medical stability of patients with advanced symptoms. Hyperglycemia and ketosis are the most life-threatening, urgent issues. Educators will frequently have patients perform self-monitoring of blood glucose during a visit to assess their skill, review equipment, or determine postprandial glucose values. If there are symptoms of ketosis, a urine or blood ketone test is recommended. Organizational procedures should be followed for the presence of ketones, but when seeking the underlying cause, questions related to the possibility of an eating disorder should be included.
Often, patients' physical appearance is the simplest factor to assess to determine the need for further medical evaluation. These symptoms include pale appearance, flushed cheeks, dry lips, dehydration, and signs of poor nutrition including dull hair, red or puffy gums, and fatigue. Nutritional deficiencies resulting from lack of food intake or purging of food can cause other symptoms such as confusion, anxiety, diarrhea, and loss of appetite. Other red flags include electrolyte abnormalities (especially potassium abnormalities), tachycardia, abdominal pain, hypotension, dizziness, and fainting. In these situations, prompt communication with the referring physician and a referral for a medical appointment with the physician is indicated.
The presence of an eating disorder without the coexistence of diabetes requires an intense multidisciplinary approach that minimally requires a psychologist, a physician, and an RD. Although there are limited published data concerning the treatment of patients with a dual diagnosis of diabetes and an eating disorder, it is clear that an expanded multidisciplinary team is required and should include the addition of a physician, an RD, and a nurse with diabetes expertise. Additionally, the RD and nurse should be trained in the treatment of eating disorders to fully understand their treatment and best support the combined treatment goals. This Diabetes Spectrum From Research to Practice section is the first comprehensive description for treating this dual diagnosis and should serve to guide such multidisciplinary teams.
In many communities, there is no organized treatment program for those with an eating disorder, let alone for those with this dual diagnosis. Many diabetes educators may feel unprepared to work with patients with the dual diagnosis. Some make the decision to obtain further education and training in the area of eating disorders to better help their patients with diabetes who also have eating disorders. Table 2 offers a list of resources that can be helpful in this regard.
To be prepared for patients at risk for or having an eating disorder, diabetes health care professionals should identify resources in their community to support treatment efforts. RDs and diabetes nurses might consider doing the following:
Determine if there are any eating disorder conferences or association meetings in your area. Attend such meetings to help identify resources in your community and to learn more about eating disorders. See Table 2 for websites of national eating disorder organizations that may have state or local chapters. Also, ask a psychologist or social worker for recommended meetings.
Make a list of professionals (by credential) who you would want to have as part of your dual-diagnosis team. Identify one or two names for each profession you want to include. Ask colleagues or contact a university professional program for recommendations.
Invite an eating disorders expert to speak at a local or state dietetic association or diabetes educator meeting. Ask him or her to address resources and the dual diagnosis. Offer to collaborate.
Start a discussion group to support the development of a treatment team and to provide ongoing development. Consider an e-mail distribution list, Facebook page, or other social media group to coordinate the discussion group and share resources and experiences.
If an eating disorder program exists in your community, reach out to its staff to help them understand the unique needs of patients with diabetes and to discuss collaborative care and treatment programs.
When diabetes educators identify a potential eating disorder in a patient with diabetes and communicate this to the referring physician, it is not unusual for them to be asked to help coordinate treatment. Completing the above steps and having a plan ready for these situations can be useful.
Once a treatment team has been established, it is important for all members to have frequent and open communication to share information concerning patients' progress, treatment plans, and treatment goals. RDs and nurses may need to have patients sign release forms to communicate with health care professionals outside of their immediate health care network. Check with your medical records department for specific policies concerning communication with other health care professionals.
The frequency of individual and group sessions depends on patients' needs and the resources available. Some programs have patients meet weekly with an RD and a psychologist, whereas others have patients meet 5 days a week with various professionals. Details of recommended treatment plans and goals are discussed in detail in the article on p. 147 of this issue. The intensity and frequency of visits is a crucial component of therapy, and diabetes educators should reinforce the need for them.
Setting small, incremental goals such as reestablishing appropriate insulin doses and normalizing eating patterns to maintain patient safety is the initial treatment focus. All members of the treatment team should keep in mind that past diabetes experiences with extreme focus on glycemic control, managing food intake, and managing body weight affects patients' current diabetes management and disordered eating behaviors.
There is a dearth of information about identifying and treating people with diabetes and an eating disorder. Research has focused on the prevalence of eating disorders, A1C levels, and prevalence of complications, with a few studies describing characteristics in select populations.3-9 Additional research is needed to increase understanding about this medical condition, who it affects, and how best to treat it. Potential research topics could include the questions shown in Table 3. Diabetes educators may be able to help facilitate such research by connecting with staff who conduct research at a university or national program.
Diabetes educators play an integral role in helping patients manage their diabetes and the aspects of their lives that diabetes affects. Because eating disorders have an enormous impact on patients' ability to manage diabetes, it is crucial that diabetes educators be familiar with the identification and treatment of these conditions and seek out resources to further their ability to care for this dual diagnosis.