Complete Nurse's Guide to Diabetes Care, 3rd Edition

Chapter 24

Depression, Anxiety, and Eating Disorders

Ann Goebel-Fabbri, PhD,1 and John Zrebiec, MSW, CDE2

1Goebel-Fabbri is in private practice in Boston, MA. 2Zrebiec is director of the Behavioral and Mental Health Unit at the Joslin Diabetes Center, Boston, MA, and a lecturer in psychiatry at Harvard Medical School, Boston, MA.

The Diabetes Control and Complications Trial (DCCT) and the U.K. Prospective Diabetes Study demonstrated that intensive management of type 1 diabetes (T1D) and type 2 diabetes (T2D) improves long-term health outcomes.1,2However, the goal of achieving near-normal blood glucose values requires a complex set of daily behaviors and problem solving involving dietary management, exercise, blood glucose monitoring, and medication management. Over the long term, it is not uncommon for patients to have difficulty sustaining the burden of these daily self-care demands and numerous lifestyle changes. It is therefore not surprising that the stress of coping with diabetes is a major risk factor for psychiatric illnesses and problems related to adhering to complex treatment recommendations.

Practical Point

Depression is two to four times more prevalent in patients with diabetes. Therefore, routine screening for depressive symptoms is indicated for this high-risk population. 2017 ADA Standards of Medical Care in Diabetes recommend screening of all patients with diabetes for depression at the initial visit and on an annual basis, or when there are significant changes in medical status, treatment, or life circumstance.3

DEPRESSION AND DIABETES

The prevalence of depression in patients with diabetes is two to four times higher than that found in the general population.4,5 Several studies suggest that patients with depressive disorders develop worse glycemic control problems and have a heightened risk of diabetes complications, such as retinopathy, nephropathy, hypertension, cardiac disease, and sexual dysfunction.6 Although depression is related to complications and disease duration, it has been found to occur relatively early in the course of diabetes, before the onset of complications.7 Therefore, the increased rate of depression and diabetes cannot be explained solely by emotional reactions to the onset of complications. Indeed, the relationship may be bidirectional because symptoms of depression, such as decreased motivation, poor energy, and hopelessness, likely interfere with adherence to diabetes treatment, leading to worse glycemic control.

Prospective longitudinal studies also have demonstrated the remarkable persistence of depression in adults with diabetes. During long-term follow-up, 73% to 79% of subjects continued to experience depressive symptoms with increased risk for those who did not take insulin, had more than two complications from diabetes, and did not graduate from high school.8,9

Symptoms of Depression

The presence of at least five of the following symptoms during the same 2-week period, including at least one of the first two, is indicative of depression:

• Depressed mood

• Loss of interest or pleasure

• Significant weight (appetite) loss or weight gain

• Insomnia or hypersomnia

• Psychomotor agitation or retardation

• Fatigue, loss of energy

• Feelings of worthlessness or guilt

• Difficulty concentrating or indecisiveness

• Thoughts of death or suicide

In a now-classic meta-analysis of 24 studies of depression, hyperglycemia, and diabetes, Lustman et al.11 reported a consistent, strong association between elevated glycated hemoglobin A1c (A1C) values (indicating chronic hyperglycemia) and depression. They were unable, however, to determine the direction of the association, so it remains unclear whether hyperglycemia causes depressed mood or if hyperglycemia is a consequence of depression. Furthermore, the research team noted that the relationship might be a reciprocal one in which hyperglycemia is provoked by depression, independently contributing to the exacerbation of depression, like a feedback loop.

Studies of T2D clearly indicate that depression and diabetes are associated, but the direction of the association is still unclear. Depression may occur as a consequence of having diabetes.12 In some instances, however, the increased rates of depression seen in patients with T2D appear to precede the onset of illness, thereby raising an entirely different hypothesis about the etiological relationship (i.e., depressive disorders themselves may place patients at risk of developing T2D). Depressed patients often decrease physical activity, increase cardiovascular risk factors by smoking, and eat high-calorie and fatty foods, placing them at higher risk of developing T2D.13,14

More research is investigating the neuroanatomic correlates of depression in T1D. Magnetic resonance imaging data from patients with T1D suggests that prefrontal cortical deficits, affected by long-term glycemic control, might play a role in the increased risk for depression.15

The bottom line is that nurses need to be alert to symptoms of depression and integrate identification of depressive problems into routine clinical care. This assessment can start with informal questions about changes in mood during the past 2 weeks or since the last visit and looking for cues that suggest the presence of depression. Examples of such cues include 1) lack of interest in self-care behaviors, 2) increased forgetfulness in taking medications or self-monitoring glucose, and 3) change in dress or appearance. In addition, several standardized and validated tools are available to assess depression. The 2016 ADA position statement on “Psychosocial Care for People with Diabetes” lists commonly used questionnaires.16

Recently, a distinction has been made between clinical depression and diabetes distress. The hypothesis is that the significant negative emotions associated with the diagnosis of diabetes, challenges of achieving and maintaining treatment targets, unending self-management demands, onset of complications, and impact on interpersonal relationships are an appropriate response to the stresses of coping with a chronic illness. Emotional distress is considered a normal and common, rather than idiosyncratic and pathological, response to diabetes. In this context, addressing the negative emotional reactions to living with diabetes does not require specialized psychiatric training. On the basis of this concept, all team members should have ongoing conversations with patients about diabetes-related distress because distress can indicate an increased risk for poor treatment outcomes.17–19 In fact, recent findings support diabetes-related distress as well as depression symptom severity as risk factors for type 2 diabetes medication nonadherence.20

Evidence indicates that treatment for depression can lead to improvements in diabetes self-management and improved glycemic control. The combination of high rates of depression in patients with diabetes and the known effectiveness of treatments for depression reinforces how critical it is to identify and treat depression early in its onset. The possibility of comorbid depression also should be considered when treating patients with worsening glycemic control and trouble adapting to diabetes. A small number of studies have demonstrated that treatment of depression, including cognitive-behavior therapy and antidepressants (particularly selective serotonin reuptake inhibitors [SSRIs]), has equivalent efficacy in depressed patients with diabetes and patients with depression alone. Ideally, referrals for treatment should be made to mental health providers who are knowledgeable about diabetes, have experience using cognitive behavioral therapy, interpersonal therapy, or other evidence-based treatment approaches, and can collaborate with the patient’s diabetes care team.

A potentially more appealing treatment option for some people is exercise. It has been demonstrated that exercise helps to improve mild depressive symptoms and the results may be enduring, but of course, depression might interfere with the motivation to start an exercise program.21

The mutual identification, support, and problem solving offered by other people with diabetes makes group therapy an increasingly popular option for treatment of depression. Thus, whatever the causal links between depression and diabetes, psychiatric treatment can improve glycemic control and reduce depressive symptoms.11–17,22

Despite the evidence for the efficacy of treatment for depression, incorporating treatment into practice has been disappointing. A variety of barriers have been identified that include a lack of screening and diagnosis by health-care providers, a lack of referral for psychotherapy and psychopharmacology, and a lack of antidepressant medication dosage adjustment to therapeutic levels by primary care providers.23

Practical Point

Treatment of depression will help people with diabetes have longer, more enjoyable, healthier lives.

ANXIETY DISORDERS AND DIABETES

All patients are anxious about their diabetes at one time or another. Whether anxiety is normal or abnormal depends on its intensity and on the duration, consequences, and circumstances that caused it. A recent prospective study found that anxiety was a significant risk factor for the onset of T2D independent of lifestyle factors and indicators of the metabolic syndrome.24 Of course, anxiety can have negative effects on regimen adherence and glycemic control. Panic episodes, in particular, have been associated with higher A1C values, more diabetic complications, and higher levels of disability and dysfunction.25

Symptoms of Anxiety

The presence of excessive worry associated with at least three of the following symptoms, with some symptoms present for more days than not in the past 6 months, is indicative of anxiety:

• Restless, keyed-up, on edge

• Easily fatigued

• Difficulty concentrating

• Irritability

• Muscle tension

• Sleep disturbance

Diagnostically, anxiety disorders encompass generalized anxiety disorder, panic disorder, obsessive-compulsive disorder, post-traumatic stress disorder, and various phobias. In addition to depression, they are some of the most disabling psychiatric illnesses and often coexist with depression. These illnesses are notorious for their chronicity, negative impact on quality of life, and interference with receiving medical care. In a review of 18 studies, Grigsby et al.26 reported that generalized anxiety disorder was present in 14% of patients with diabetes compared with 4% for the general population. Elevated anxiety levels were present in 40% of subjects, with no difference in prevalence between individuals with T1D and those with T2D. Women with diabetes were more likely to have higher levels of anxiety than men with diabetes. The Behavioral Risk Factor Surveillance System estimated the lifetime prevalence of generalized anxiety to be 19.5% in people with either type 1 or type 2 diabetes.27

Anxiety commonly focuses on fears of hyperglycemia and complications or fears of hypoglycemia and feeling out of control.28 Occasionally, individuals may experience a phobic avoidance of needles, infusions and blood glucose checks. Conversely, individuals might compulsively check blood glucose levels or monitor their CGM.29 Ordinarily, chronic anxiety (commonly called stress) is created simply by the effects of diabetes on day-to-day life. The demands of self-care are complex, never-ending, and often frustrating. Patients can feel overwhelmed, guilty, angry, fearful, or unmotivated, particularly when blood glucose levels are high or unpredictable despite their best efforts.

Similar to depression, routine screening for anxiety is indicated for this high-risk population. 2017 ADA Standards of Medical Care in Diabetes recommend screening for all patients with diabetes who show anxiety symptoms and when there are significant changes in medical status, treatment or life circumstance.3 (This assessment may start with behavioral observation and informal questions about fears and worries during the past month or since the last visit.) In addition, there are standardized and validated tools available to assess anxiety and fear of hypoglycemia. The 2016 ADA position statement on “Psychosocial Care for People with Diabetes” lists commonly used surveys.16

The psychophysiological effects of stress on blood glucose levels also have been studied. Although most people with diabetes report that stress affects their blood glucose levels, the results of research have been inconsistent, with some studies reporting blood glucose responses (usually hyperglycemic) to stress and others finding no response.30 Thus, although evidence reporting the effects of stress on blood glucose is inconclusive, its potential as a factor influencing the achievement of self-care goals in diabetes should be considered in the treatment of patients with diabetes.

Practical Point

Anxiety about diabetes tends to peak at distinct periods of stress, which can include the initial crisis of diagnosis, the onset of major complications, and failure to achieve the desired therapeutic response. These crises give the nurse a unique opportunity to have an enormous impact on patients and their families, who likely will be more receptive to outside support at these times.

Diabetes is a disease that affects the family, and the behavior of the family can have an effect on the person with diabetes. Family members may add stress by being overprotective, accusatory, unrealistic, or uninvolved with diabetes care. The person with diabetes may complicate these family dynamics by rejecting family support or becoming overly dependent, leaving family members feeling frustrated and worried. Once again, the nurse plays a crucial role in helping families find effective ways to communicate about diabetes management.

Treatment Recommendations

Psychopharmacological treatments for anxiety, including the SSRIs, appear to be effective for patients with diabetes, although they have not been studied closely with either type of diabetes. Likewise, although limited formal research has been done on other forms of psychotherapeutic intervention and diabetes per se, it is reasonable to assume that other accepted forms of psychotherapy would be equally effective in diabetes.31 A recent systematic review by Fisher et al.32 found that a wide range of interventions improved quality of life and healthy coping skills, including cognitive-behavioral, cognitive-analytic, family systems, and multisystemic therapies, as well as support groups and problem-solving interventions. Stress management training holds promise as a cost-effective treatment for improving glycemic control.33 Cognitive-behavioral treatments are being used successfully for a range of anxiety disorders. In general, this approach identifies maladaptive thought patterns and troublesome behaviors and instructs patients in developing more adaptive substitute thoughts and behaviors. Blood Glucose Awareness Training (or other similar, evidence-based intervention) can be used to help reduce fears of hypoglycemia and help re-establish symptom detection in persons with hypoglycemic unawareness.34Relaxation training and hypnotic suggestion may have beneficial effects for individuals suffering from needle phobias (for more on helping the patient deal with his or her diabetes, see Chapter 23, Living with Diabetes). Ideally, referrals for treatment of anxiety should be made to mental health providers who are knowledgeable about diabetes and who are able to collaborate with the patient’s diabetes care team.

EATING DISORDERS AND DIABETES

Despite the promise of risk reduction for the long-term complications of T1D, one negative side effect of intensive diabetes management may be weight gain. For example, during the first 6 years of follow-up in the DCCT, the patients in the intensively treated group gained an average of 10.45 lb more than patients in the standard treatment cohort.35 The most recent follow-up of these patients, 9 years after the completion of the DCCT, indicated that once patients on intensive treatment gained weight, this weight was difficult to lose.36 A survey of patients’ responses to the recommendations of the DCCT documented that women with T1D were especially concerned about tight glucose control causing weight gain.37,38 It remains unclear whether this same risk is present now that more physiologic insulin replacement is possible when using basal-bolus insulin regimens or insulin pump therapy. Some clinicians suspect that this risk is significantly decreased with the availability of these newer diabetes management tools. Whether or not the risk of weight gain exists, researchers and clinicians argue that the attention to food portions, blood glucose levels, and exercise associated with intensive diabetes management may parallel the rigid thinking about food and body image characteristic of women with eating disorders. Thus, aspects of diabetes treatment themselves may place women with diabetes at heightened risk of developing eating disorders. Women with T1D may use insulin restriction (i.e., administering reduced insulin doses or omitting necessary doses altogether) as a unique symptom of caloric purging. Intentionally induced glycosuria is a powerful and dangerous weight-loss behavior for people with T1D.39

Practical Point

Researchers estimate that 10–20% of girls in their mid-teen years and 30–40% of late teenaged girls and young adult women skip or reduce their insulin doses to lose weight.

Symptoms of Anorexia Nervosa

The following symptoms indicate anorexia nervosa:10

• Restriction of energy intake relative to requirements, leading to a significantly low body weight in the context of age, sex, development trajectory, and physical health. Significantly low weight is defined as a weight less than minimally normal or, for children and adolescents, weight less than that minimally expected.

• Intense fear of gaining weight or becoming fat, or persistent behavior that interferes with weight gain, even though at a significantly low weight.

• Disturbance in the way in which one’s body weight or shape is experienced, undue influence of body weight or shape on self-evaluation, or persistent lack of recognition of the seriousness of the current low body weight.40

Studies suggest an increased risk of eating disorders among female patients with T1D. Jones et al.41 reported that young women with T1D have 2.4 times the risk of developing an eating disorder and 1.9 times the risk for subclinical eating disorders (i.e., when symptoms of disordered eating do not meet the level of severity to warrant a formal diagnosis) compared with age-matched women without diabetes.41 Intermittent insulin restriction for calorie purging also has been found to be a common practice among women with T1D. For example, in women and girls with T1D between the ages of 13 and 60 years, Polonsky et al.42 found that 31% reported intentional insulin restriction. Rates of restriction peaked in late adolescence and early adulthood, with 40% of women and girls between 15 and 30 years old reporting intentional restriction. Similar rates of eating disorder symptoms were also reported in a large cohort of children and adolescents with T1D.43 Work by Peveler et al.44 indicated that eating problems continue to increase past age 30 years with an average age of onset of 23 years.45Additionally, studies show that this behavior, even at a subclinical level of severity, places women at heightened risk for the medical complications of diabetes. Women reporting intentional insulin restriction had A1C levels an average of 2–3% points higher, more frequent episodes of diabetic ketoacidosis, higher rates of hospital and emergency room visits, and higher rates of microvascular complications than women who did not report insulin restriction.42,46,47 In a longitudinal study, Rydall et al.46 reported that after 4 years of eating disordered behavior, 86% of women classified as highly eating disordered had retinopathy, compared with 43% and 24% of women with moderate or no reported eating disturbance, respectively.

Insulin restriction was found to triple the risk of mortality during an 11-year follow-up study.47 The same study, however, also found that some women do report stopping insulin restriction. Those who stopped restricting insulin were able to maintain a stable body mass index (BMI) over the follow-up period while those who continued reporting insulin restriction experienced an increase in BMI. Most important, women who stopped insulin restriction reported thinking differently about insulin and weight, no longer fearing that healthy glycemia and appropriate insulin treatment automatically would lead to weight gain. The data showed that the opposite was true as well; fearing that insulin would induce weight gain was associated with the emergence of insulin restriction as a compensatory behavior.48

Although the large majority of research on eating disorders and T1D focuses on insulin restriction as a central symptom, not all patients with eating disorders and T1D restrict insulin. For example, patients with anorexia and T1D require significantly less insulin than usual as a result of severe calorie restriction and related weight loss. Their eating disorder may go undetected for a while because their glucose values are likely to be in target range. This pattern may get praised by the health-care team until the patient reaches a notably low weight or develops recurrent hypoglycemia, such that their eating disorder is discovered. Additionally, patients with bulimia and T1D may not always use insulin restriction to purge calories. For example, they may self-induce vomiting or turn to excessive exercise and other means of purging. These behaviors may not have as strong an impact on glycemia as insulin restriction, possibly making it more difficult to detect eating disorders in these patients. However, they do convey a significantly higher risk of mortality.49

Symptoms of Bulimia Nervosa

The following symptoms indicate bulimia nervosa:

• Recurrent episodes of binge eating—an episode of binge eating is characterized by both of the following:

—Eating, in a discrete period of time (e.g., within any 2-h period), an amount of food that is definitely larger than what most individuals would eat in a similar period of time under similar circumstances.

—A sense of lack of control over eating during the episode (e.g., feeling that one cannot stop eating or control what or how much one is eating).

• Recurrent inappropriate compensatory behavior to prevent weight gain, such as self-induced vomiting, misuse of laxatives, diuretics, or other medications; fasting; or excessive exercise.

• Binge eating or compensatory behaviors both occur, on average, at least once per week for 3 months.

• Self-evaluation is unduly influenced by body shape and weight.

• The disturbance does not occur exclusively during episodes of anorexia nervosa.40

Disordered eating behaviors are often well hidden. Once established as a longstanding behavior pattern, the problem of frequent insulin restriction may be particularly difficult to treat. For this reason, early detection and intervention are crucial.50 The 2017 American Diabetes Association standards of care recommend routine screening for eating disorders with T1D patients who have longstanding hyperglycemia and unexplained weight loss. As simple a question as, “Do you take less insulin than you should?”47,48 can be helpful in screening for insulin restriction when patients present with persistently elevated A1C levels or unexplained DKA.

Debate is ongoing about whether eating disorder screening tools should be diabetes specific or whether more widely used general screening questionnaires can suffice. The Diabetes Eating Problem Survey–Revised (DEPS-R) was designed as a diabetes-specific screening tool for eating disorder symptoms. It is a 16-item self-report questionnaire that takes <10 minutes to complete. It has been shown to be reliable and valid in several samples of patients with T1D.51,52 The DEPS-R is an important contribution to the field because some studies show that using non–diabetes-specific screening tools may result in misinterpretation of findings, particularly given that diabetes management requires a focus on issues of food, weight, and exercise.53

The SCOFF is a widely used general eating disordered screening tool that is brief enough for use in routine clinical practice. It recently was adapted to create the mSCOFF, a diabetes-specific version of the SCOFF that includes the following five items: 1) Do you make yourself Sick because you feel uncomfortably full? 2) Do you worry you have lost Control over how much you eat? 3) Have you recently lost 14 lb (One stone) in a 3-month period? 4) Do you believe yourself to be Fat when other people say you are too thin? 5) Would you say that Food dominates your life? The diabetes-adapted mSCOFF replaces the fifth question: Do you ever take less insulin than you should? Early research was has been conducted to evaluate the use of this tool in subjects with diabetes.54 Because it is so short, the mSCOFF may be more practical and easily adopted for use in routine clinical care.

The final diabetes-specific screening tool is the Screen for Early Eating Disorder Signs in Persons with T1DM (SEEDS). It is an attempt to identify those patients who may be experiencing early signs of risk rather than those already engaged in actual eating disorder behaviors. It develops low risk, moderate risk, and high risk scores and creates both a total score and subscale scores for body image, feelings, and quality of life. Unlike the DEPS-R and the mSCOFF, the authors decided not to ask any questions about insulin restriction or any questions pertaining to T1D itself, because of their belief that such questions could be suggestive to patients not yet restricting insulin.55

Treatment Recommendations for Type 1 Diabetes

The 2008 International Conference on Eating Disorders and Diabetes Mellitus developed consensus guidelines for screening and treatment of T1D and eating disorders. Although these guidelines were developed from expert clinical experience, they would be strengthened with supporting empirical evidence.56–58 The following recommendations summarize the guidelines. A multidisciplinary team approach is considered to be the optimal treatment for both eating disorders and diabetes. When designed to treat a patient with both diabetes and an eating disorder, such a team should include an endocrinologist or diabetologist, a nurse educator, a nutritionist with eating disorder or diabetes training, and a psychologist or social worker with eating disorder expertise to provide weekly individual therapy. Depending on the level of comorbid depression and anxiety, a psychiatrist also may be needed for psychopharmacological evaluation and treatment. As stated above, little research has examined treatment efficacy for eating disorders in the context of diabetes; however, a large volume of research on treatment outcomes in eating disorders in the general population supports the use of cognitive-behavioral therapy in combination with antidepressant medications as the most effective treatment.59 These approaches would need to be adapted slightly to directly address the role of insulin restriction as the means of calorie purging as well as other psychological issues specific to T1D and its management. The research thus far seems to indicate that this is a more complicated population to treat and that treatments of greater intensity and duration may be required.

Weekly psychotherapy is strongly recommended. Early in the treatment, monthly appointments with the endocrinologist, nurse educator, and nutritionist may be necessary to maintain medical stability. Laboratory tests (especially A1C and electrolytes) and weigh-ins should occur at each of these medical appointments. Some patients may require a medical or psychiatric inpatient hospitalization until they are medically stable and emotionally ready to engage in treatment as outpatients.

With regard to diabetes management, the treatment team must be willing to set incremental goals that the patient feels ready to achieve. Early in treatment, intensive glycemic management of diabetes is not an appropriate target for a person with diabetes and an eating disorder. The first goal is to establish medical safety for the patient, focusing on the prevention of DKA and the acute onset of complications. Studies show that rapid A1C improvement in individuals with longstanding hyperglycemia is associated with early onset of retinopathy60–62 and severe, treatment-induced neuropathy.63 Therefore, ophthalmologists and neurologists recommend slowly improving glycemia in these patients, but evidence has not yet clarified how much improvement to aim for and over what period of time. Establishing a guideline for prevention of treatment-induced complications would represent significant progress.

Helping patients to identify and anticipate possible treatment challenges can help to solidify the treatment relationship and possibly decrease the risk of treatment dropout. The first challenge most patients face is weight gain associated with improved blood glucose. If they have been routinely restricting insulin and are dehydrated at the start of treatment, patients need to be reassured that this weight gain is related to fluid retention or “insulin edema.” Patients are likely to report feeling fat and uncomfortable, and will need to be reassured that this is temporary. Because eating disorder patients are exquisitely sensitive to body shape and weight changes, this rapid weight gain that comes just as they are starting to engage in treatment and see blood glucose improvements can be frightening. In fact, they may reveal that similar experiences triggered relapse in their past. Once fluid levels have stabilized, patients’ ongoing concerns about weight must also be taken seriously by the treatment team. When patients attempt to lower their blood glucose ranges and experience unwanted weight gain unrelated to fluid, their frustrated attempts to lose the weight may also raise their risk of relapse.

Fear of hypoglycemia may also lead patients with diabetes to aim for elevated blood glucose. Some patients report that treating hypoglycemic reactions can trigger them into episodes of binge eating.64,65

Other patients worry about taking in the extra calories required for treatment of hypoglycemia and therefore try hard to avoid it. It may be helpful to anticipate these concerns with patients. To reduce their risk of bingeing or over-treating, patients should be encouraged to use fast portion-controlled treatments for hypoglycemia like glucose gels or tablets, which may be less tempting to overeat.

Gradually, the team can build toward increased doses of insulin, increases in food intake, greater flexibility in meal plans, regularity of eating routines, and more frequent blood glucose monitoring. Newer insulin analogs show evidence of modestly improved weight profiles. Research is needed to develop additional insulin analogs that do not promote weight gain. As newer agents come to market, we will learn more about how to use these tools to optimize treatment. However, careful consideration of how to match specific patients with appropriate tools will be needed in order to minimize the risk of patients misusing these newer agents as well.66

Symptoms of Binge Eating Disorder

The presence of the following symptoms indicates a binge eating disorder:

• Recurrent episodes of binge eating—an episode of binge eating is characterized by both of the following:

—Eating, in a discrete time period (e.g., within any 2-hour period), an amount of food that is definitely larger than what most individuals would eat in a similar period of time under similar circumstances.

—A sense of lack of control over eating during the episode (e.g., a feeling that one cannot stop eating or control what or how much one is eating).

• The binge eating episodes are associated with three (or more) of the following:

—Eating much more rapidly than normal

—Eating until feeling uncomfortably full

—Eating large amounts of food when not feeling physically hungry

—Eating alone because of feeling embarrassed by how much one is eating

—Feeling disgusted with oneself, depressed, or very guilty afterward

• Marked distress regarding bingeing is present.

• The binge eating occurs, on average, at least once per week for 3 months.

• The binge eating is not associated with recurrent use of inappropriate compensatory behaviors as in bulimia nervosa and does not occur exclusively during the course of bulimia nervosa.40

Because obesity is a significant risk factor in T2D, recurrent binge eating may increase the chances of developing this form of diabetes. Research indicates that a distinct subgroup of obese adults (20–46%) engage in recurrent binge eating.67

The literature on binge eating in T2D is starting to grow beyond its initial studies, which relied on small, nonrepresentative samples. Binge Eating Disorder (BED) is the most frequently observed eating disorder in this population with up to 40% of patients with T2D—men and women—reporting BED.68 Findings are mixed regarding the association between A1C and binge eating symptoms69. Some studies have found no association between binge eating and/or BED and A1C70,71 while others have found positive associations. Kenardy and colleagues reported that the frequency of binge eating predicted blood glucose levels after controlling for BMI and exercise level72 while Mannucci’s group found a significant positive correlation between severity of binge eating symptoms and A1C values73. Other research indicates that T2D patients with BED have higher A1Cs, BMIs, triglyceride levels, and rates of hospitalization than patients without BED74. Examining things from another angle, a large follow-up study of a cohort of patients who had received eating disorder treatment reports that 16 years after treatment one in every three patients treated for BED had developed T2D.75 Finally, disordered eating symptoms are associated with poor quality of life in T2D and present an impact that is unique for A1C, diabetes duration, and presence of diabetes complications.76 The large-scale, longitudinal TODAY study also found a strong association between binge eating, higher rates of extreme obesity, symptoms of depression, and decreased quality of life in its adolescents with T2D.77

Treatment

No research thus far has evaluated specific treatment of binge eating or BED within a T2D population. The following are suggestions about small adaptations to empirically supported BED treatments that might help address the specific needs of patients with T2D. These ideas are based on clinical experience.

Cognitive Behavioral Therapy and Interpersonal Therapy78 are the two treatment approaches that have the most empirical support for treating binge eating and BED. Either approach can be successfully applied to these problems in T2D with some modifications. As is the case in T1D, treatment should involve a multidisciplinary team approach—ideally one in which team members are aware of common psychological struggles related to T2D, though this can be difficult to find.79

Treatment begins with the recommendation to adopt a reliable and routine eating pattern in order to prevent the cycle of food restriction and hunger triggering binge eating, which can then reinforce the perceived need for restricting food again.78 Patients are encouraged to keep food records including the time of day, types and amounts of food consumed, context and feelings, and if they define the eating episode as a binge or not. When integrated into T2D treatment, patients should also record what their blood sugar values are prior to and approximately 2 hours after the meal, snack, or binge. This may help patients to learn the impact that their eating patterns have on their diabetes management and may increase their motivation to actively address them.

Medical providers should understand the struggle and shame involved in binge eating and take a sensitive and nonjudgmental approach, especially since T2D treatment will often involve recommendations to lose weight. The patient may sometimes feel as if the medical and the psychological sides of the team are providing contradictory advice. Patients may interpret their doctor’s weight-loss recommendations to mean rigid dietary restriction as opposed to the routine eating plan recommended by the eating disorder specialists. This underscores the importance of clear communication between team members in order to emphasize both regular eating as well as an approach that involves moderate portions (neither restriction nor binge eating) for slow and sustainable weight loss.

Binge eating and BED treatments also emphasize identifying negative thoughts and teaching healthier strategies for coping with painful emotions.78 Eating disorder specialists should be ready to identify those thoughts and feelings that may be specific to diabetes. For example, patients may blame themselves for developing diabetes, may perceive diabetes complications as inevitable or even deserved, and may feel at fault for blood sugar and weight variations. These examples of diabetes-specific ideas can be readily integrated into cognitive therapy approaches. Patients will also benefit from learning healthier coping skills to help them prevent binge eating during times of distress.

Medications for T2D can be divided into two broad categories: those associated with weight gain and those that are weight neutral or even associated with weight loss. Some T2D treatment experts are now recommending avoiding those medicines with the risk of weight gain when possible and beginning treatment by using those that do not have this side effect profile. The ADA standards of care recommends consideration of adjuvant treatment with GLP-1 agonists to help with the regulation of hunger and fullness signals. Such approaches may help reduce patient frustration, increase their sense of self-efficacy, and promote trust in their treaters.

SUMMARY

Nursing takes a holistic approach to chronic care, seeing the physical, emotional, and spiritual issues that contribute to the health problems of an individual. Many times, a patient will see the nurse as the safest person to talk with to share feelings of anger, depression, or anxiety. The role of the nurse can be pivotal in helping patients to seek treatment (medication or counseling) to address these mental health problems.

When a nurse suspects psychiatric problems, it can be helpful to remind the patient, the family, and the treatment team that diabetes management is burdensome and requires support. This support can come from family members, friends, coworkers, and a multidisciplinary diabetes treatment team. Both the patient and treatment team must be encouraged to work collaboratively to set small, attainable diabetes treatment goals that can increase in complexity over time. Because of the strong connection between psychological factors and diabetes management, it is crucial to include mental health treatment in the multidisciplinary treatment approach, especially when self-management problems arise.

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