Patients with an eating disorder and type 1 diabetes require specialized care. There is a lack of information on current treatment practices for these patients in a residential eating disorder treatment setting. Identify current practices for treating patients with an eating disorder and type 1 diabetes in a residential eating disorder treatment setting. This was a qualitative research study. Interviews were conducted via zoom video conferencing and later transcribed verbatim. Four researchers conducted qualitative data analysis using a case study design approach. Data from transcribed interviews of 18 clinical nutrition managers at 18 different eating disorder treatment facilities across the United States were analyzed. Only clinical nutrition managers employed at eating disorder treatment facilities that offered a residential level of care were eligible for participation. Four themes were identified through qualitative case study analysis: 1) Nutrition interventions for patients with diabetes, 2) Medical diabetes management, 3) Interdisciplinary diabetes team, and 4) Clinical nutrition manager’s assessment of diabetes care. Clinical nutrition directors were knowledgeable about nutrition related interventions at their respective treatment facilities. There was an apparent lack of communication and lack of knowledge across disciplines. The most frequent feedback was the need and desire for more education related to treating patients with type 1 diabetes. Type 1 Diabetes Mellitus (T1DM) is an autoimmune disease that destroys pancreatic beta cells, leading to insulin deficiency. About 1.25 million Americans have T1DM. Treatment with exogenous insulin is required to maintain normal blood glucose levels and is necessary throughout life. About 30 million people in the United States are affected by Eating Disorders (EDs). EDs are serious mental illnesses with the highest rates of suicide and co-morbid mental illness. EDs include anorexia nervosa, bulimia nervosa, binge eating disorder. Eating Disorder-Diabetes Mellitus Type 1 (ED-DMT1) is the term used to describe someone with type 1 diabetes and a co-occurring ED. Diabulimia has been used to describe EDs in people with T1DM, referring to intentional withholding of insulin for weight loss. ED-DMT1 is a more correct and inclusive term when referring to a person with an ED and T1DM because it includes all ED behaviors a person may be engaged. Treatment of T1DM itself may increase the risk of developing an ED due to weight gain with insulin initiation, dietary restraint, the ability to lose weight through insulin omission and other factors. About one-third of people with T1DM intentionally omit insulin, and this behavior is a cause of recurrent episodes of diabetic ketoacidosis. Diabetic ketoacidosis is a serious, potentially life-threatening condition that can result from untreated high blood glucose levels. A list of 333 ED treatment facilities in the United States was obtained via e-mail from the alliance for eating disorders awareness. Facilities were excluded from participation if they were not located within the United States, did not offer residential level of care, were not an ED-specific facility, or did not have identifiable contact information. The point of contact at each facility was the Clinical Nutrition Manager (CNM). Of potential participants, 104 facilities met the inclusion criteria. The CNM at each facility was contacted via one to four rounds of phone calls and/or e-mails and the interview process was explained. Of those contacted, 29 CNMs at facilities located in 16 different states were willing to participate.

Results from this study are reflective of the experiences of 18 CNMs from 18 residential eating disorder treatment facilities across the United States. Table 1 contains self-reported descriptive information about each facility. Four themes were identified through qualitative case study analysis: 1) Nutrition interventions for patients with diabetes, 2) Medical diabetes management, 3) Interdisciplinary diabetes team and 4) Clinical nutrition manager’s assessment of diabetes care. Below is a description of each theme including direct CNM quotes. 

Regarding dietitian monitoring of carbohydrate intake, five CNMs reported not having target macronutrient ranges but two of those indicated having carbohydrate counts for menu items with actual intake monitored by the dietitian. CNM 2 stated there were no set target ranges, but there’s always a little more protein than there is carb. There’s always fat, there’s vegetables. More monitored approaches included having target macronutrient ranges (e.g., 45%-60% calories from carbohydrates) and limiting the number of carbohydrate exchanges at meals (e.g., no more than 4 carbohydrate exchanges or 2-3 carbohydrate exchanges). Other approaches included individualized macronutrient ranges, patients logging carbohydrate intake at meals, and having a goal total in mind of carbs and have it split up pretty evenly throughout the day (CNM 17).

Most CNMs (n=11) reported use of oral supplements (e.g., boost^®, ensure^®, and glucerna^®) for patients who were unable or unwilling to complete their food at meals/snacks. Only CNM 12 identified using a diabetes-specific formula if the standard facility formula was not tolerated. CNM 10 stated that patients were expected to consume 100% at meals and snacks and that they did not use nutritional supplements because, our staff is very, very skilled in techniques and strategies and motivational techniques to get clients through those difficult (eating) experiences. Only three facilities offered tube feedings and typically bolus or nighttime tube feedings were used.

In conclusion, ED-DMT1 represents unique co-occurring disorders that require specialized treatment by an interdisciplinary team of professionals. This team must be educated about EDs and T1DM. There is a great need for future research to address the development, application and efficacy of education materials for clinicians and to develop standard of care recommendations for the treatment of ED-DMT1 in residential ED treatment settings.

Warm Regards,
Joseph Kent
Journal Manager
Journal of Clinical Nutrition & Dietetics.