‘Thin at any cost’—managing type 1 clients with an eating disorder : S Hart, S Twigg, S...

Pract Diab Int June 2005 Vol. 22 No. 5 Copyright © 2005 John Wiley & Sons, Ltd. 155

COMMENTARIES

Eating disorders are more prevalent in young peoplewith type 1 diabetes than in the general population.1

This is perhaps not unexpected in a group where somuch emphasis is placed on dietary measures, andwhere tight glycaemic control may be associated withincreased body weight compared with non-diabeticpeers. Not surprisingly, insulin manipulation is the mostcommon way in which young people with type 1 diabetesseek to control their weight; however, many of these willnot qualify as having an eating disorder. Where an eat-ing disorder is diagnosed, bulimia or EDNOS (eatingdisorder not otherwise specified) rather than anorexianervosa are the most common.2

Unfortunately, the success rates for treatment of eat-ing disorders are lower in people with diabetes com-pared with non-diabetic clients.3 Referral can often bedelayed and accessing a specialist service may be a chal-lenge in itself. These disorders are, by nature, secretiveand this paper by Susan Hart and colleagues highlightsthe difficulty of identifying them in the diabetic clinic atan early stage. The paper offers a valuable insight intothe challenges faced by the in-patient eating disorderteam trying to manage these patients with type 1 dia-betes on a day-to-day basis. It also offers some usefulmanagement strategies. It is clearly essential that the twospecialist teams (eating disorder and diabetes) workclosely together and keep communicating. The ‘control’needed for diabetes management will be at odds with

the need for patients to be less restrictive with their foodintake as part of their eating disorder treatment pro-gramme. Eating disorder staff may not be regularly deal-ing with diabetes management and likewise the diabetescare team may not fully appreciate the manipulation offood and insulin which occurs in this client group.

The prevalence of eating disorders in patients withtype 1 diabetes is significant and this implies that thesepatients are under the noses not only of those workingin hospitals, as outlined in the paper, but also of com-munity teams. Naturally, understanding and empathywill improve care offered by specialist teams, but thosenot working within this context will also need to have anawareness of the kinds of issues this paper raises.

Anna Clark, Diabetes Specialist Dietitian, John PeaseDiabetes Centre, Sherwood Forest Hospitals NHSTrust, Kingsmill Hospital, Sutton in Ashfield, UK

References1. Jones JM, Lawson ML, Daneman D, et al. Eating disorders

in adolescent females with and without type 1 diabetes:cross sectional study. BMJ 2000; 320: 1563–1566.

2. Nash J, Skinner TC. Eating disorders in type 1 diabetes.Pract Diabetes Int 2005; 22: 139–145.

3. Daneman D, Olmsted M, Rydell A. Eating disorders inyoung women with type 1 diabetes: prevalence, problems,and prevention. Horm Res 1998; 50(Suppl 1): 79–86.

‘Thin at any cost’ – managing type 1 clientswith an eating disorderS Hart, S Twigg, S Abraham, J Russell. The practical management of patients with type 1 diabetes requiringin-patient care due to an eating disorder. Pages 165–170.

The next few years will witness the introduction of aseries of novel technologies to augment existing thera-pies for the management of type 1 and type 2 diabetes.Over the years much has been made of advances ininsulin technology; however, with the possible exceptionof reduced hypo incidence the benefits offered to dia-betes care may have been more limited than has beensuggested. Novel approaches to caring for people withdiabetes, and perhaps equally importantly preventingthe pandemic of type 2 diabetes the world is witnessing,are urgently needed.

In his excellent article, Professor Nauck reviews GLP-1 and the incretin mimetics. This novel therapeuticclass will become available in the USA later in 2005 andmost probably in Europe in 2007. In offering the poten-

tial to intervene in the natural history of type 2 diabetesat an early stage these agents open up exciting possibili-ties. For instance, the prospect of gaining glycaemic con-trol without the weight gain often seen at present is attrac-tive, particularly when associated with no risk of hypogly-caemia. The potential for future molecular manipulationto render the therapy long acting also brings the prospectof weekly or even monthly dosing regimens.

No new therapy comes without caveats however. As agut hormone which reduces gastric motility, the effectsof GLP-1 therapy on the significant group of people withdiabetes who have sub-clinical gastroparesis areunknown. The effects of altered gastric emptying on thepharmacokinetics of other concomitant therapies arealso uncertain. It should also be remembered that a

GLP-1 mimetics: a potential panacea fortype 2 diabetes?MA Nauck. Glucagon-like peptide 1 (GLP-1) and incretin mimetics for the treatment of diabetes. Pages 171–179.

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