Can  We  Eat  Dessert?  Managing  Binge  Eating  Disorder  and  Co-­‐occurring  Type  2  Diabetes  By  Meg  Salvia,  MS,  RDN,  CDE  Walden  Behavioral  Care  &  Meg  Salvia  Nutri;on  

Objectives  

•  Summary  of  diagnosis  and  management  of  diabetes  

•  Summary  of  diagnosis  and  management  of  binge  ea;ng  disorder  

•  Prevalence  &  significance  of  co-­‐occurring  diseases  

•  Nutri;on  management  of  diabetes,  then  binge  ea;ng  disorder  

•  Synthesized  nutri;on  management  of  co-­‐occurring  diagnoses  

•  Case  Studies  

•  Ques;ons  &  Discussion    

Type  2  Diabetes  (T2DM)  •  Hallmarks  of  T2DM:  Progressive  disease  course  •  Insulin  resistance  •  Decreased  beta  cell  func;on  

Normal   Prediabetes   Diabetes  

Fas1ng  BG  (mg/dL)  

<  100   100-­‐125   126    

A1c  (%)   4.0-­‐5.6   5.7-­‐6.4   6.5  

Body  releases  insulin  

Insulin  resistance  

Hyperinsuilnemia  (increased  excre;on)  

Rela;ve  insufficiency  

Decreased  beta  cell  func;on/produc;on  

Exogenous  insulin  

Hyperglycemia  

Binge  Eating  Disorder  (BED)  •  Diagnos;c  criteria  recently  added  to  DSM-­‐5  •  Recurrent  episodes  of  binge  ea;ng  •  Episode  is  characterized  by:  

•  Ea;ng  an  amount  of  food  that  is  definitely  larger  than  what  most  people  would  eat  under  similar  circumstances  within  a  discrete  period  of  ;me  A  sense  of  lack  of  control  over  ea;ng  during  the  episode  

•  Associated  with  3  or  more  of  the  following:  •  Ea;ng  more  rapidly  than  normal  •  Ea;ng  un;l  feeling  uncomfortably  full  •  Ea;ng  large  quan;;es  when  not  hungry  •  Ea;ng  alone  due  to  embarrassment  •  Feeling  disgusted  with  oneself,  depressed,  or  guilty  

•  Marked  distress  •  Occurs  at  least  1x  per  week  for  3  months  •  Not  associated  with  compensatory  behaviors  

Prevalence  

Type  2  Diabetes    29  million  9%  of  popula;on  (6%  in  Vermont)  

37%  of  adults  have  prediabetes  

Binge  Ea;ng  Disorder  9  million  

2.8%  

Diagnosis  is  rela;vely  new,  Treatment  underu;lized  

Both  Dx  (es;mated)  

~3.5  million  12%  of  T2DM  

Impact  and  Interaction  •  BED  is  most  common  ED  dx  in  T2DM  pa;ent  popula;on  •  Does  binge  ea1ng  contribute  to  development  of  T2DM?  •  Binge  ea;ng  episodes  can  contribute  to  weight,  obesity  status  •  “Independent  of  BMI,  female  binge  eaters  are  more  likely  to  develop  DM.”    

•  Does  T2DM  dx  lead  to  binge  ea1ng  behaviors?  •  Pa;ents  with  DM  at  increased  risk  for  ED  

•  Depression  &  die;ng  history  may  play  a  role  

•  Does  BED  lead  to  worse  T2DM  outcomes?  •  ED  in  T2DM  associated  with  worse  metabolic  &  psychological  outcomes  

•  ED  +  DM  associated  with  increased  risk  of  complica;ons  

•  Binges  can  consist  of  large  CHO  quan;;es    •  Some  research  finds  no  difference  in  A1c  with  BED  dx  

Through  the  Lens  of  the  Patient:  Life  With  DM  •  Psychosocial  considera;ons  •  Depression,  guilt,  and  shame  

•  Fear  of  complica;ons  

•  Tools  for  managing  BG  •  BG  checking  

•  Frequency  •  Not  everyone  with  T2DM  self  monitors  BG  

•  Lifestyle  modifica;ons  •  Nutri;on  (details  to  come)  

•  Physical  ac;vity  •  150  minutes/week  

•  Recommenda;ons  for  weight  loss    •  Impact  greatest  early  in  disease  progress  

•  Research  supports  weight  loss  prevents  progression  of  preDM  to  T2DM  

MNT  Physical  Ac;vity  

Lifestyle  Modifica;ons  

Diabetes  Medications  

Mekormin  Combina;on  Therapy  

Insulin  

•  Medica;ons  that  increase  risk  of  hypoglycemia:  •  Sulfonylureas    •  Megli;nides  •  Insulin  •  Not  Mekormin    

•  Insulin  requires  alen;on  to  CHO  intake:  •  Fixed  daily  doses:  consistent  CHO  amount  &  ;ming  •  Intensive  insulin  therapy  (similar  to  T1DM)  

Diabetes  911  What  ED  Providers  Need  to  Know  •  What  are  the  medical  crises  that  can  happen  in  T2DM?  •  Hyperglycemia    Treat  with  medica;on  or  hospitaliza;on  

•  Diabe;c  ketoacidosis  (DKA)  •  Hyperosmolar  Hyperglycemic  Syndrome  (HHS/HHNS)  

•  Hypoglycemia    Treat  with  CHO  •  Recall  that  insulin  or  sulfonylureas  increase  risk  

Hyperglycemia  Symptoms   Hypoglycemia  Symptoms  

Frequent  thirst     Shakiness  

Frequent  urina;on   Swea;ng  or  clamminess  

Headaches   Pounding  heart,  anxiety  

Tiredness,  fa;gue   Irritability,  impa;ence  

Blurry  vision   Weakness,  fa;gue  

Difficulty  concentra;ng   Confusion  

Nutrition  for  Diabetes:    The  Basics    •  Goals  (from  the  ADA)  •  Improve  glycemic  control    

•  Reduce  CVD  risk  •  Achieve  &  maintain  body  weight  goals  

•  Delay  or  prevent  complica;ons  

•  Maintain  pleasure  of  ea;ng  •  Provide  prac;cal  tools  for  day-­‐to-­‐day  management  

•  Op;mal  mix  of  macronutrients:  Doesn’t  exist  •  Amount  of  CHO  is  the  most  important  factor  in  BG  impact  

•  Quality  of  fat  is  key  •  Protein  +  CHO  increases  insulin  response  

Nutrition  for  Diabetes:    Carbohydrates  •  Carbohydrate  coun;ng  •  Why  60  grams  of  carbohydrate  at  a  meal?  

•  Dietary  Guidelines  (2010):  50-­‐65%  of  daily  kcal  from  CHO  

•  2000  kcal  diet  =  250-­‐300  g  CHO  per  day    60  g  per  meal  and  15-­‐30  g  per  snack  

•  What  if  2000  kcal  per  day  is  an  inappropriate  goal?  

•  Low  Carb  =  less  than  45%  of  kcals  from  CHO  •  ADA  Diet    

•  Moving  away  from  one-­‐size-­‐fits-­‐all    ea;ng  palerns  

•  Glycemic  Index  •  Glycemic  load  

•  Fiber  

Nutrition  for  Diabetes:  First  Steps  for  ED  Providers  •  Get  a  clear  understanding  of  the  DM  treatment  plan  •  Diagnosis  (prediabetes  versus  diabetes)  •  Labs:  A1c,  fas;ng  BG,  BG  palerns  •  Medica;on  plan  &  BG  monitoring  

•  Ask:  Does  your  DM  provider  know  about  BED  dx  or  binge  behaviors?  

•  First  few  weeks:  will  BED  treatment  influence  DM  treatment?  •  Assess  understanding  of  DM  nutri;on  recommenda;ons  

•  What  is  a  CHO?  What  does  15  g  of  CHO  look  like?  

•  Exchange-­‐based  systems:  1  grain  =  15-­‐20  g  CHO  

•  Changes  in  P.O.  intake  can  some;mes  result  in  needed  medica;on  changes    collaborate  &  communicate  

•  Understand  nutri;on  and  weight  messages  pt  may  have  heard  from  DM  perspec;ve  

Through  the  Lens  of  the  Patient:  Life  With  BED  •  Psychosocial  Considera;ons  •  Guilt  &  shame  (sound  familiar?)  

•  Die;ng  history  •  Rigidity  or  Black-­‐and-­‐White  Thinking  

•  Tools  for  Managing  BED  •  Interdisciplinary  team  

•  Therapist/clinician    •  Medica;on  management  (MD  or  NP)  

•  Successful  psychological  models:  CBT,  DBT  

•  Goals:    •  Interrupt,  reduce  binge  behaviors  •  Meet  nutri;on  needs  and  support  short-­‐  and  long-­‐term  health  

•  Heal  rela;onship  with  food  •  Build  addi;onal  coping  skills  in  place  of  food  

Nutrition  &  BED:  The  Basics  •  Meal  plans  &  meal  palerns  •  Provide  nutri;onally  adequate  plan    ini;al  goal  is  not  weight  loss  but  binge  symptom  reduc;on  

•  Meal  plan  con;nuum:    •  From  structure  &  support  to  intui;ve  ea;ng  

•  Assess  frequency,  quan;ty,  and  content  of  binges  •  If  you  can…  lots  of  secrecy  here  

•  Key  Concept:  Neutrality  •  Permission  means  no  food  is  off  limits  

•  Challenge  foods  &  dessert  included  

Hunger  

Denial  

Binge  

Shame  &  Resolve  

5  Key  Principles  for  BED  •  Adequacy  

•  Ea;ng  at  least  3  meals  per  day  

•  Snacks  between  meals  

•  Balance  •  All  food  groups  included  in  meals  

•  Variety  •  Try  different  foods  within  each  food  group  •  Mix  up  setng,  prepara;on,  and  environment  

•  Modera;on  •  The  other  side  of  the  coin  of  adequacy    •  Por;on  sizes  

•  Nourishment  •  Food  feeds  our  bodies  &  souls  •  There  are  other  reasons  to  eat  apart  from  hunger  •  Not  the  “hunger  &  fullness”  or  “mindful  ea;ng”  diet  

Intuitive  Eating  

•  Reject  the  diet  mentality  

•  Learn  about  hunger  &  fullness  

•  Enjoyment  &  sa;sfac;on  

•  Cope  with  emo;ons  without  using  food  

•  Respect  your  body  and  health  

•  Depression  &  psychological  impact  is  huge  •  Connect  to  mental  health  support  is  essen;al  for  ED  pa;ents  

•  Iden;fy  binge  behaviors    you  might  be  the  first  to  know!  •  Ques;ons  to  ask:  

•  Is  your  ea;ng  different  when  you’re  alone  versus  with  others?  •  Does  your  ea;ng  ever  feel  out  of  control,  or  like  you  couldn’t  stop  if  you  

wanted  to?  •  Palerns  to  look  for:  

•  Skipping  breakfast,  lunch,  PO  intake  earlier  in  the  day  to  compensate  •  Elevated  BG  (especially  in  the  morning)  without  explana;on    •  Missing  BG  checks  when  dosing  insulin  •  Inexplicable  weight  palerns  (rapid/linear  gain,  not  matching  PO  intake,  

episodes  of  significant/day;me  restric;on)  •  Inability  or  reluctance  to  log  food  or  BG  •  “I  know  what  to  do,  I  just  need  to  do  it.”  

•  DM  Nutri;on  counseling  for  binge  behaviors  •  Diffuse  charged  language  and  black-­‐and-­‐white  thinking  •  Bringing  food  decisions  into  a  neutral  place  

BED  911      What  DM  Providers  Need  to  Know  

BED  +  DM:  Synthesized  Plan  •  Goals:    

•  Meet  nutri;on  needs  without  exacerba;ng  behaviors  

•  Improve  glycemic  control  for  short-­‐  and  long-­‐term  health  

•  Clarify  and  support  adherence  to  DM  plan  

•  Reduce  frequency  &  quan;ty  of  binge  behaviors  

•  Help  pa;ents  manage  emo;on  &  psychological  distress  

•  Provide  ongoing  support  and  educa;on  

BED  +  DM:  Synthesized  Plan  •  Basics:  First  to  reduce  binge  behaviors  (days  to  weeks)  •  Inclusion  of  carbohydrates    

•  Por;on  sizes  &  exchanges  •  Assess  degree  to  which  CHO  coun;ng  is  appropriate  

•  Balancing  carbs  with  protein  &  fat  •  Regular  meals  and  snacks  •  Help  manage  ;ming  and  hunger  •  Establish  BG  monitoring  plan  

•  Intermediate  goals:  (weeks  to  months)  •  Prac;ce  health-­‐suppor;ng  behaviors  •  Foster  curiosity  (BG  monitoring  around  individual  choices…  details  next)  

•  Advanced  topic:  Heal  rela;onship  with  food  (months  +)  •  Awareness  of  hunger  and  sa;ety  cues  •  Permission  around  food  and  neutrality  •  Build  trust  

Desserts  &  Challenge  Foods  •  Keys:  Trust  &  Curiosity  

•  Tools  for  building  TRUST  through  nutri;on  counseling:  •  Structured  introduc;on  •  Challenge  meals  with  you  •  Stair-­‐step  planning  tool  •  Hunger  scale  •  “Seven  hungers”  

•  Curiosity:  Specific  BG  palerns  •  BG  “check”  versus  “test”  

Weight:  Circling  Back  to  an  Important  Topic  •  Recall:    •  Weight  loss  is  a  recommenda;on  for  prediabetes,  early  T2DM  •  Weight  loss  is  not  a  goal  of  BED  tx  programs,  intui;ve  ea;ng  

•  So,  if  weight  loss  is  a  goal,  which  diet  should  we  recommend?  •  Research  doesn’t  support  any  par;cular  diet  for  weight  loss  •  Die;ng  owen  results  in  increased  weight  

•  Research  on  mindful  ea;ng  or  intui;ve  ea;ng  on  glycemic  control  &  weight  goals  is  emerging  and  intriguing  

•  Reframe:  •  Interrupt  palern  of  ongoing  weight  gain  •  Reduce  frequency  and  quan;ty  of  binges  •  Improve  glycemic  control  (reduce  risk  of  complica;ons)  •  Weight  loss  may  occur  –  clinically  significant  wt  loss  doesn’t  need  to  be  large  

Weight:    Impact  of  Reducing  Binge  Behaviors  

IBW  range  

Binge  behaviors  

Elevated  weight  

Case  Studies  

Resources:  Diabetes  Avert,  et  al.  Nutri1on  therapy  recommenda1ons  for  the  management  of  adults  with  diabetes.  

Diabetes  Care  2013.  

References  •  Evert  AB,  Boucher  JL,  et  al.  “Nutri;on  Therapy  Recommenda;ons  for  the  Management  of  

Adults  with  Diabetes.”  Diabetes  Care,  2013.  •  Franz  MJ,  Boucher  JL,  et  al.  “Evidence-­‐Based  Diabetes  Nutri;on  Therapy  Recommenda;ons  

Are  Effec;ve:  the  Key  is  Individualiza;on.”  Diabetes,  Metabolic  Syndrome,  and  Obesity,  2014.  

•  Jakubowicz  D,  Wainstein  J,  et  al.  “Fas;ng  Un;l  Noon  Triggers  Increased  Postprandial  Hyperglycemia  and  Impaired  Insulin  Response  awer  Lunch  and  Dinner  in  Individuals  with  Type  2  Diabetes:  A  Randomized  Clinical  Trial,”  Diabetes  Care,  2015.  

•  ADA  Standards  of  Medical  Care  in  Diabetes,  Diabetes  Care  Supplement,  2016  •  Miller  CK,  Kristeller  JL,  et  al.  “Compara;ve  Effec;veness  of  Mindful  Ea;ng  Interven;on  to  a  

Diabetes  Self-­‐Management  Interven;on  Among  Adults  with  Type  2  Diabetes.”  JAND  2012  •  Yevvon  YC,  Wen-­‐Bin  C.  “Means  Yield  to  Ends  in  Weight  Loss:  Focusing  on  “How”  vs  “Why”  

Aspects  of  Losing  Weight  Can  Lead  to  Poorer  Regula;on  of  Dietary  Prac;ces,”  JAND  2015  •  Franz  MJ,  Boucher  JL,  et  al.  “Lifestyle  Weight-­‐Loss  Interven;on  Outcomes  in  Overweight  

and  Obese  Adults  with  Type  2  Diabetes:  A  Systema;c  Review  and  Meta-­‐Analysis  of  RCT,”  JAND  2015  

•  Celik  S,  Kayar  Y.  “Correla;on  of  Binge  Ea;ng  Disorder  with  Level  of  Depression  and  Glycemic  Control  in  Type  2  DM  Pa;ents,”  General  Hospital  Psychiatry,  2015  

•  Racicka  E,  Brynska  A.  “Ea;ng  Disorders  in  Children  and  Adolescents  with  Type  1  and  Type  2  Diabetes  –  Prevalence,  Risk  Factors,  Warning  Signs,”  Psychiatr.  Pol.,2015.  

•  Nicolau  J,  Simo  R.  “Ea;ng  Disorders  are  Frequent  Among  Type  2  Diabe;c  Pa;ents  and  Are  Associated  with  Worse  Metabolic  and  Psychological  Outcomes,”  Acta  Diabetol,  2015.  

Questions  &  Conversation    

Thank  you  for  your  ;me  and  alen;on!  

         Meg  Salvia,  MS,  RD,  CDE            Walden  Behavioral  Care                        Meg  Salvia  Nutri;on            megsalvia.com            meg@megsalvia.com            @meg_salvia