Inpatient Management of Eating Disorders in ... - Diabetes Spectrum

From Research to Practice/Eating Disorders and Diabetes

In Brief Individuals with both eating disorders and type 1 diabetes (ED-DMT1) who are medically or psychiatrically unstable may require inpatient treatment to stabilize glucose control and establish regular eating patterns. The purpose of this article is to review the clinical issues and strategies relevant to the treatment of ED-DMT1 within the inpatient setting.

Inpatient Management of Eating Disorders in Type 1 Diabetes

Ovidio Bermudez, MD, Heather Gallivan, PsyD, Joel Jahraus, MD, Julie Lesser, MD, Marcia Meier, RN, CDE, and Christopher Parkin, MS

Adolescent girls and young women with type 1 diabetes have an increased risk for both subthreshold and fullsyndrome eating disorders.1 Eating disorders in individuals with type 1 diabetes (ED-DMT1) are of clinical concern because they increase the risk of diabetic ketoacidosis (DKA) and diabetes-related medical complications (particularly retinopathy and neuropathy), and they are associated with higher rates of hospital and emergency room visits. 2–5 Although long-term therapy for patients with ED-DMT1 often occurs in outpatient settings, those who are medically or psychiatrically unstable require inpatient treatment.6 A treatment team composed of staff with specialties in both eating disorders and diabetes care who communicate on a regular basis is crucial to the care of ED-DMT1 patients. This team is usually composed of specialists from diabetes and eating disorders departments, including an endocrinologist; certified diabetes educators, including a registered nurse and a registered dietitian; a primary care physician; a psychiatrist; a therapist; and a care manager. Members of the team should thoroughly understand both diagnoses. The purpose of this article is to review the clinical issues and strategies relevant to the treatment of ED-DMT1 within the inpatient setting. It is important to note that few studies have been conducted to comprehensively assess the efficacy of the treatment approaches discussed in this Diabetes Spectrum Volume 22, Number 3, 2009

article; thus, many of the recommendations presented here are based on the authors’ personal experience and clinical judgment. Admission and Assessment Admission to inpatient care In the acute medical care setting, ED-DMT1 patients who intentionally withhold insulin will usually present with hyperglycemia, dehydration, electrolyte imbalances, and DKA. The medical care of these conditions calls for careful fluid, electrolyte, and insulin management. Also, careful attention must be paid to accurately gathering the pertinent history from patients and family members (or other caregivers) and to monitoring patients for further self-sabotage. For example, if a patient who was planning to withhold insulin is now given insulin after a meal, her fear of the calories she has consumed may lead her to induce vomiting, and she may be very creative about it, despite being supervised. As patients with ED-DMT1 decompensate and are referred to medical acute care settings, it is crucial that clinical information includes their diagnosis and the details of their behavior. This information must be provided to those who will care for these patients while in crisis, so that they will not operate in a vacuum. Although many patients enter the treatment process through an acute care setting, those with less severe symptoms or issues may be admitted directly to an inpatient/residential 153

eating disorders care facility. In either case, it is important to ensure that the facility offers the necessary array of general medical, specialty medical, psychological, nutritional, and emergency services; any one or a combination of these services may be needed to care for these patients safely. Some of the more specialized services differentiate ED-DMT1 patients from other eating-disordered patients. Without the resources in place to meet any of this population’s potential needs, the patients should not be accepted into the facility for treatment. An important part of the admissions process is clearance to travel, especially if it requires flights or any other form of prolonged travel. Providers must obtain pertinent records, medical information, and direct contact with key previous providers when feasible. ED-DMT1 patients must be considered at high medical risk through the transfer and admissions process. Even if they appear to be medically stable at the time of initial or telephone assessment, rapid decompensation may ensue in transit or as they have one last go at their behaviors before submitting to the admission. Medical assessment Once patients are admitted to a facility, the next step is to perform a timely and comprehensive medical assessment. This assessment should include a comprehensive history and physical exam. In addition to the traditional components of any medical assessment, it should include three specific, additional components. First, an assessment of current status is needed with specific attention to acute diabetes-related or eating disorder–specific decompensation. Examples would be severe abnormalities in blood glucose, acid-base status, dehydration, electrolyte abnormalities (representing acute complications of diabetes), or severe malnutrition, bradycardia, orthostasis, syncope, prolonged QTc interval on electrocardiogram, hypothermia, or electrolyte abnormalities (representing acute complications of eating-disordered behaviors). When one of these conditions is identified with a degree of severity to warrant urgent or emergency attention, priority should be given to providing immediate and appropriate care. 154

Table 1. Assessment Instruments for ED-DMT1 • • • • •

Rosenberg Self-Esteem Scale Eating Disorder Examination Questionnaire (EDEQ) Patient Health Questionnaire–9-item depression scale (PHQ9) Eating Disorders Stages of Change State/Trait Anxiety Inventory (STAI)

Second, special attention should be paid to identifying complications of poorly controlled diabetes that may have been accelerated by the insulin manipulation. Such complications include nephropathy, retinopathy, or cardiac, circulatory, gastrointestinal, growth, or peripheral and autonomic nervous system involvement. Third, special attention should be paid to identifying complications of the eating disorder such as cardiac conduction issues, gastrointestinal dysfunction, autonomic dysfunction, identifiable nutritional deficiencies, and osteopenia/osteoporosis. A plan of care with an appropriate timeline should be delineated for any identified, nonacute complication of diabetes or eating disorders and should be part of the overall treatment plan for each patient. Psychiatric assessment A comprehensive assessment of current status should be conducted at the time of admission. The assessment should include a mental status examination and risk assessment (for suicide and self-harm risk) to establish the level of psychiatric care needed. Table 1 presents a list of assessment tools. In cases in which immediate medical risk outweighs acute psychiatric risk but both are present (i.e., patients in DKA who also express suicidal thoughts), a medical hospitalization with one-on-one patient supervision and other measures to protect patients from self-harm may need to be implemented in a medical setting. The opposite may hold true for patients whose suicide risk is greater than the medical urgency (i.e., patients with a plan for suicide with clear intent who may have severe hyperglycemia but without acidosis), in which case, they may then need to go to a psychiatric crisis stabilization unit with required medical consultations. The psychiatric assessment should confirm a diagnosis of ED-DMT1 and any other dual diagnosis or psychiatric comorbidity. It is also helpful to include an assessment of readiness to change or accept treatment; ambivalence at the point of entry into treatment is Diabetes Spectrum Volume 22, Number 3, 2009

quite common in most patients with eating disorders and perhaps even more important to assess when severe medical complications are a real and potentially imminent risk. Inpatient Treatment After patients are admitted to the most appropriate care setting and level of care, some practical issues specific to the needs of this population should be considered. Initially, the aim should be toward modest blood glucose control with a gradual move toward tighter control. In most cases, the care team will assume responsibility for the diabetes care and gradually have patients resume responsibility as they demonstrate the ability and willingness to do so. This transition typically occurs in three steps. First, all care is assumed by staff, including monitoring of blood glucose and measuring and administration of insulin. Next, there is joint care by staff and patients (e.g., the nurse and patient will agree on an insulin dose, and the patient will draw and self-administer it under the direct supervision of staff). Third, patients will gradually resume full responsibility for their diabetes self-care with diminishing staff supervision in preparation for return to outpatient care. This will be helpful even for patients who feel they are experienced and capable of managing their diabetes. Medical management Often, ED-DMT1 patients have withheld insulin for prolonged periods of time and have lived in a moderate to severe hyperglycemic state. They may become very susceptible and symptomatic with decreases in their serum glucose levels, even if in the normal range. Symptomatic “relative hypoglycemia” may be very scary for them, and sustained anxiety is not helpful for their diabetes management. Gradual and consistent improvement in control will help to alleviate these fears and recruit their trust and cooperation in the process. For example, a patient who is admitted with an A1C of 13% (reflecting an estimated average glu-


Table 2. Approaches to Inpatient Treatment of ED-DMT1 Cognitive Behavioral Therapy7–Enhanced for Eating Disorders (CBT-E) CBT-E is an empirically supported treatment that tailors cognitive behavioral therapy (CBT) to the full range of eating disorders in a treatment approach that emphasizes the reintroduction of regular eating, weight exposure, and treating body image concerns. Dialectic Behavioral Therapy (DBT)7 DBT is a behavioral treatment that utilizes principles of CBT and typically includes weekly individual sessions, weekly group skills training, therapist consultation meetings, and some form of behavior generalization (e.g., brief telephone-skill coaching between sessions), all with the aim of replacing maladaptive behaviors (e.g., suicide gestures or attempts, other forms of self-harm) with skillful, effective ones. Family-Based Therapy (FBT)6,8 FBT for treating eating disorders has gained support in recent years as an alternative to traditional therapy.7,8 This approach entails a specific type of therapy in which the family is enlisted as a resource for patients’ treatment. In this therapeutic modality, adolescents with anorexia nervosa are viewed as no longer capable of making sound choices regarding their health and thus require help from parents to overcome the illness.9 Although adolescence is a time for increasing independence from parents, family therapy for adolescents with eating disorders, including those with ED-DMT1, is one of the most useful treatments. cose of > 345 mg/dl during the past 3 months) may feel hypoglycemic when the blood glucose level is reduced to 180 mg/dl. In such situations, the aim would be to consistently and gradually improve serum glucose levels to run < 300 mg/dl for the first few days, then < 250 mg/dl for the next few days, then < 200 mg/dl, and so on until blood glucose is normalized. Although there are some differences among programs, many agree that if patients have been using an insulin pump, it should be discontinued, and the gradual process toward improved control should start with subcutaneous insulin administration. This includes establishing a basal insulin (long-acting insulin analog or intermediate-acting insulin) and a bolus insulin (fast-acting insulin analog) plan that often includes a prescribed number of units per gram of carbohydrate consumed at a meal or snack. In addition, a hyperglycemia correction plan using a fast-acting insulin analog for blood glucose levels above the individualized target range should be determined. Frequent testing of blood glucose should be conducted at the beginning of treatment. Testing frequency can be gradually decreased as blood glucose control becomes more stable and predictable. For example, patients may be instructed to begin with testing before meals and snacks, at bedtime, and twice during the night. Testing frequency can then be adjusted as needed. Patients with ED-DMT1 may note faster improvements in their A1C with improved glycemic control than patients with diabetes but without

an eating disorder. This is an unexplained observation to date, but it implies that more frequent A1C testing should be considered in this population. Research regarding this clinical observation is warranted. In many situations, it is protocol to use the institution’s testing equipment while patients are in acute care to accommodate documentation requirements (e.g., the electronic medical record). Once patients transition to a lesser level of care, they may resume using their own blood glucose meters. One important challenge in insulin management is the timing of doses in relation to food intake. Typically, insulin is administered before food intake; however, patients may refuse to eat or may limit their intake at meals. If a rapid-acting insulin analog or regular insulin has been administered, this would put them at risk for hypoglycemia. Preparations to treat hypoglycemia should include immediate availability of glucose tablets or simple-carbohydrate foods or drinks and a glucagon kit. If patients want to resume using an insulin pump, this may be warranted once they have established a track record of appropriate use of insulin and their urges to misuse insulin have subsided, especially for patients who have intentionally misused their pump in the past. The need for weight recovery is not always an issue because some of these patients may be at a normal weight or even overweight. When weight recovery is indicated, it is important to be sensitive to the possibility of fears regarding that issue; weight gain often comes with improved glycemic Diabetes Spectrum Volume 22, Number 3, 2009

control. As patients sense their weight restoration, their fears may intensify and lead to “slip ups” in their diabetes self-care, just as restriction or purging might occur in patients with anorexia or bulimia. Reinforcement of diabetes self-care education and teaching throughout the course of treatment is therefore important. Also, consider the timing of introduction of physical activity and the impact it may also have on glycemic control. As is the case with other presentations of eating disorders, relapse prevention should be included in all phases of treatment, without losing sight of the fact that these patients will be returning to an anti-recovery environment. In addition, management of comorbid psychiatric disorders may be an important part of relapse prevention because, if left untreated, these disorders may contribute to the dysregulation and distress that can lead to relapses. Psychosocial intervention A primary goal of inpatient treatment is to establish regular eating with a prescribed meal plan. This is central to recovery for eating disorders across the diagnostic spectrum. The inpatient setting provides a unique opportunity to reintroduce a regular eating pattern by providing a monitored, exposureresponse prevention protocol. Several approaches, such as cognitive behavioral therapy–enhanced for eating disorders (CBT-E), dialectic behavioral therapy (DBT), and family-based therapy (FBT) are used (and often combined) to address the behavioral 155

issues associated with ED-DMT1 (Table 2). For example, one can combine elements of these treatment approaches to facilitate more comprehensive intervention strategies. The inpatient milieu is structured according to principles of DBT, and staff members attend weekly education and consultation meetings in addition to receiving specialized training in DBT. Protocols are in place to manage egregious behaviors utilizing a DBT-informed approach, including validating approaches as well as teaching to promote more adaptive coping strategies in the moment.

DBT strategies to enhance motivation and teach validation techniques to family members are folded into FBT. FBT is initiated while patients are on the inpatient unit. This phase of care includes involvement of patients’ parents or caregivers in all aspects of meal planning and the diabetes care plan. Parents participate in family therapy and educational sessions about menu planning, family meals, diabetes selfmanagement, and eating disorders. Because the FBT approach requires more active involvement of parents or caregivers in monitoring the meal plan and diabetes management, parents may worry about damage to the

parent-child relationship in taking back control of both eating and diabetes care. To address this concern, staff members can work closely with the families to reduce criticism, hostility, and emotional overinvolvement while promoting proactive coaching and problem-solving skills. For adult patients with ED-DMT1, the program emphasizes the importance of involving patients’ support system. Although it is advised that all adolescents are treated with FBT, treatment programs may choose to also integrate CBT into the program to focus on body image for ED-DMT1. Patients tend to struggle with body

Table 3. Sample Diabetes Care Plan from Park Nicollet Melrose Institute Date Initiated or Modified

Diabetes Care

Procedures: Patient is to perform all tasks, but always under observation

Blood glucose testing

Test before meals and before bedtime • The hospital meter reading must snack be used as the basis for any type of Additional tests if patient feels hypoglycediabetes treatment mic or if endocrinologist orders more • Inpatient and outpatient, patient Food record sheets to be done for inpauses own meter and own supplies tient and outpatient • Back-up supplies are available Change lancet once per day at supper blood glucose test

Blood glucose range Meal plan

Insulin administration for food

(Glucose Target Range) • Patient to follow meal plan given by registered dietitian • Patient to work with dietitian to confirm grams of carbohydrate or carbohydrate choices, if necessary • Replacements for meals or snacks should be measured as with any other patient on the unit • If the carbohydrates do not match the insulin that was given, it can be corrected at the next mealtime if high or with glucose tablets if the patient has hypoglycemia later on • The number of carbohydrate grams in the replacement will be very close to the number of carbohydrate grams the patient took for the meal • Insulin type: • Mode of delivery:

Insulin administration for hyperglycemia (“correction” or “sliding” scale)

Alterations or Additions to Care Plan/Date

• Bolus (food) insulin is given before eating • Short needle syringes are stocked on the unit

• Give additional insulin for high numbers based on doctor’s orders • Do not withhold food for high blood glucose values continued on p. 157

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Hyperglycemia/ ketone testing

• Test urine ketones if blood glucose is > 250 mg/dl twice in a row or if patient is feeling sick • Contact endocrinologist if ketones are moderate to large • Keep checking ketones at every void until negative • If showing ketones, encourage patient to drink 8 oz of water per hour until negative • Extra insulin given by physician order

• Ketone strips are stocked on the unit

Hypoglycemia/ treatment

• If below give 15 g of carbohydrate in the form of 4 round or 3 square glucose tablets • If patient continues to have symptoms of hypoglycemia after 15 minutes, recheck blood glucose and re-treat with glucose tablets as necessary • If low at meals or snack-time: ■■ Give 4 round or 3 square glucose tablets ■■ Give meal- or snack-time insulin as prescribed and have patient eat planned meal/snack

• Patient should bring own glucose tablets • Glucose tablets are stocked on the unit

Activity/exercise

• Exercise criteria must be met for patient to participate in any Physical Recovery Skill Building activity • Ill and/or has moderate to large ketones: patient should be excluded from exercise until ketones are trace to negative; contact endocrinologist • Test blood glucose before exercise: May exercise if blood glucose is ■■ 70–400 mg/dl ■■ If < 70 mg/dl, have 30 g of carbohydrate in form of glucose tablets or 8 oz of juice ■■ If 71–100 mg/dl, have 15 g of carbohydrate in form of glucose tablets • Test blood glucose after exercise: ■■ If < 70 mg/dl, give 15 g of carbohydrate in form of glucose tablets ■■ If blood glucose is higher than target range, do not correct at this time • Encourage extra water • Wait until next mealtime to correct • Use the mealtime blood glucose reading to determine correction dose

Insulin pump

• Patient must sign hospital pump agreement • Patient can change own insertion set, under supervision • Under 18 years of age cannot use pump while in hospital


Table 3. SampleCare Diabetes Care Park Plan Nicollet from Park Nicollet Melrose Institute from p. 156 Table 3. Sample Diabetes Plan from Melrose Institute , continued

• This is a hospital-wide requirement • Change every 2–3 days

Park Nicollet Melrose Institute, Minneapolis, Minn., 2009.


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image on the inpatient unit because of the reintroduction of insulin. Weightrelated negative self-evaluation has been found to be a significant predictor of relapse in patients with eating disorders. Diabetes Education and Management Diabetes self-management education from a diabetes educator is an important part of the recovery process. A complete assessment of patients’ knowledge about their diabetes and the care involved is crucial. Clinicians should not make assumptions regarding patients’ knowledge of diabetes or diabetes management. It is important that patients begin to take responsibility for their diabetes management; reintroduction of diabetes self-management is a crucial step in their treatment. For many patients, this is the first time they have performed self-monitoring of blood glucose, administered insulin, or eaten according to a regular schedule for several months or years. Emphasis on complete symptom control and following the meal plan is a priority of recovery. Table 3 presents a sample diabetes care plan. (A thorough exploration of this topic can be found in the article on p. 159 of this issue.) Summary ED-DMT1 patients who are medically or psychiatrically unstable require

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inpatient treatment.6 The immediate goals of inpatient care are to stabilize glucose control and establish regular eating patterns. Although many patients enter the treatment process through an acute care setting, those with less severe symptoms or issues may be admitted directly to an inpatient/residential care facility. The immediate focus of inpatient treatment is to stabilize glucose levels, address complications, and restore normal eating patterns. However, the reintroduction of diabetes self-management behaviors and the successful adoption of those behaviors is the long-term goal of care. A treatment team composed of staff with specialties in both eating disorders and diabetes care who communicate on a regular basis is crucial to the care of ED-DMT1 patients.

References Jones JM, Lawson ML, Daneman D, Olmsted MP, Rodin G: Eating disorders in adolescent females with and without type 1 diabetes: cross sectional study. BMJ 320:1563–1566, 2000

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Polonsky WH, Anderson BJ, Lohrer PA, Aponte JE, Jacobson AM, Cole CF: Insulin omission in women with IDDM. Diabetes Care 17:1178–1185, 1994

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4 Colas C: Eating disorders and retinal lesions in type 1 (insulin-dependent) diabetic women. Diabetologia 34:288, 1991

Steel JM, Young RJ, Lloyd GG, Clarke BF: Clinically apparent eating disorders in young diabetic women: associations with painful neuropathy and other complications. BMJ (Clin Res Ed) 294:859–862, 1987

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Working Group on Eating Disorders: Practice guideline for the treatment of patients with eating disorders. Am J Psychiatry 163:5–54, 2006

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Stone MH: Management of borderline personality disorder: a review of psychotherapeutic approaches. World Psychiatry 5:15–20, 2006

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Eisler I, Dare C, Hodes M, Russell G, Dodge E, Le GD: Family therapy for adolescent anorexia nervosa: the results of a controlled comparison of two family interventions. J Child Psychol Psychiatry 41:727–736, 2000

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Ovidio Bermudez, MD, is medical director of the Eating Disorders Program at the Laureate Psychiatric Clinic and Hospital in Tulsa, Okla. Heather Gallivan, PsyD, is the lead psychologist, Joel Jahraus, MD, is the executive director, and Julie Lesser, MD, is the program director at the Melrose Institute at Park Nicollet in Minneapolis, Minn. Marcia Meier, RN, CDE, is program manager, patient services, at the International Diabetes Center at Park Nicollet in Minneapolis, Minn. Christopher Parkin, MS, is president of CGParkin Communications, Inc., in Carmel, Ind.