How to approach a patient suspected of having type 1 diabetes and an eating disorder?

Approaching Patients with Suspected Type 1 Diabetes and Eating Disorders

When suspecting an eating disorder in a patient with type 1 diabetes, use a direct but compassionate approach that focuses on specific behaviors rather than accusations, and employ validated screening tools like the DEPS-R (Diabetes Eating Problems Survey-Revised) to guide your assessment. 1

Initial Assessment Approach

Creating a Safe Environment

• Speak with the patient alone, without family members present (starting at age 12 or when developmentally appropriate) 1
• Use a non-judgmental tone and normalize the discussion
• Emphasize that your goal is to help improve their health outcomes, not to criticize

Key Screening Questions

1. Insulin Use Patterns:

   • "Have you ever reduced or skipped your insulin doses to manage your weight?" 1
   • "Do you sometimes take less insulin than recommended for your carbohydrate intake?"
   • "Have you tried 'riding the basal' (only using background insulin without bolusing for meals)?" 1

2. Eating Behaviors:

   • "Do you worry about your weight or body shape?"
   • "Have you recently lost weight or had unexplained hyperglycemia?" 1
   • "Do you feel uncomfortable eating around others?"
   • "Do you ever feel out of control with your eating?"

3. Diabetes Management:

   • "How do you feel about carbohydrate counting and food tracking?"
   • "What challenges do you face with your diabetes management?"
   • "How do you handle high blood glucose readings?"

Red Flags to Watch For

Clinical Indicators

• Unexplained weight loss with hyperglycemia 1
• Recurrent diabetic ketoacidosis (DKA) episodes
• Elevated HbA1c inconsistent with reported self-monitoring
• Extreme concern about weight gain associated with insulin therapy
• Frequent hypoglycemia or wide glucose fluctuations

Behavioral Warning Signs

• Secretive eating behaviors
• Excessive exercise patterns
• Anxiety around food choices or carbohydrate counting
• Knowledge of precise calorie counts but poor diabetes management
• Manipulating insulin delivery devices or technology 1
• Reluctance to be weighed during appointments

Validated Screening Tools

Recommended Screening Instruments

• DEPS-R (Diabetes Eating Problems Survey-Revised) - specifically designed for T1DM 1
• Modified SCOFF questionnaire - adapted for diabetes 1
• SEEDS (Screen for Early Eating Disorder Signs) in persons with T1D 1

Multidisciplinary Management Approach

Team Composition

• Endocrinologist/diabetes specialist
• Mental health professional with eating disorder expertise
• Registered dietitian with experience in both diabetes and eating disorders 1
• Primary care provider

Communication Strategy

• Avoid focusing exclusively on weight or glycemic control
• Present findings as health concerns rather than behavioral criticisms
• Use collaborative language: "We need to work together on this"
• Emphasize that eating disorders with T1DM (sometimes called "diabulimia") carry significantly higher mortality risk than either condition alone 1

Common Pitfalls to Avoid

• Don't focus solely on improving HbA1c initially, as this may worsen eating disorder behaviors 1
• Don't set unrealistic glycemic targets that may increase anxiety
• Don't assume all weight loss is intentional
• Don't blame the patient for poor adherence
• Don't separate diabetes care from eating disorder treatment 1
• Avoid excessive focus on carbohydrate counting if it triggers disordered behaviors

Follow-Up Plan

• Schedule more frequent appointments during initial assessment
• Establish clear communication channels between all team members
• Set realistic, small goals focused on health rather than numbers
• Consider family-based treatment approaches for adolescents 1
• Monitor for depression and anxiety, which frequently co-occur 1

By using this structured approach to questioning and assessment, you can identify patients with type 1 diabetes who may be struggling with eating disorders and connect them with appropriate multidisciplinary care to improve both their diabetes management and eating disorder symptoms.