1. The Risk of developing Eating Disorders in young adults with & without T1DM in South India CHRISTIAN MEDICAL COLLEGE & HOSPITAL, VELLORE, INDIA Mini Joseph, Asha HS, Priya Mammen† & Nihal Thomas Department of Endocrinology, Diabetes and Metabolism, †Department of Child & Adolescent Psychiatry Unit, Mental Health Centre

2. Christian Medical College, Vellore South India 2600 bedded, Tertiary care Educational & Research centre Started in 1900 - Dr Ida S Scudder Caters to neighbouring States & countries.

3. DEPARTMENT OF ENDOCRINOLOGY, DIABETES & METABOLISM GENERAL DIABETES CLINIC SPECIAL CLINICS – FOOT CLINIC – GDM CLINIC – YOUNG ADULTS TYPE 1CLINIC – EYE CLINIC – BARIATRIC CLINIC – THYROID CLINIC – PITUITARY CLINIC OUT REACH PROGRAMS SCHOOL PROGRAMS HEALTH CAMPS PUBLIC AWARENESS ACTIVITIES

4. DEPARTMENT OF ENDOCRINOLOGY, DIABETES & METABOLISM Facilitator Physician Dietician Diabetes Nurse educator INTEGRATED APPROACH Diabetes Educator Physician Nutritionist Support Groups

5. Prosthetist and orthotist PMR physician Physiotherapist Vascular surgeon Diabetes Podiatric Nurse INTEGRATED DIABETES FOOT CLINIC Endocrine Physician

6. BARIATRIC CLINIC NUTRITIONIST ENDOCRINOLOGIST PSYCHIATRIST SOCIAL WORKER BARIATRIC SURGEON

7. Reshape Discussion at Scudder Junior School Healthy Class Award SCHOOL HEALTH AWARENESS PROGRAM AND EDUCATION- SPADES 2015- “HEALTHY SNACKS”

8. More than 80 Camps conducted over last 6 years.. Covering over 15,000 people..

9. World Diabetes Day- Public Awareness Programs.. DIABETES-AN EPIDEMIC

10. IDF 2015 - 415 million worldwide – Diabetes mellitus 1 in 11 adults have diabetes (IDF Atlas 2015)

12. Prevalence of DM IDF 2015-USA has the highest (11%). China and India have the highest total numbers of people with diabetes — 110 million and 69 million, respectively In Italy there are 3.5 million DM cases in 2015.

14. T1DM - Commonest metabolic disorders of childhood 542,000 children worldwide are affected (IDF 2015)

15. T1DM… T1DM occurs due to the autoimmune destruction of beta cells predisposed by genetic and precipitated by environmental determinants In the South-East Asia Region (SEAR) the Indian population having the largest incidence (2013) Incidence in South India 10.5/100,000/year (below 15 years of age in the four year period from 1991 to 1994)

16. WHY ?-T1DM & EATING DISORDERS Literature…Young T1DM patients - a higher risk of developing eating disorders They have to place great emphasis in each meal-acceptable PPBS Intense diet consciousness-early stage- increases patient’s risk Since T1DM and Eating Disorder affect largely the young adult population, these disorders tend to coexist in this age group

17. Eating Disorder Diagnostic and Statistical Manual of Psychological Disorders 5 th ed. Anorexia nervosa: an obsessive fear of weight gain, refusal to maintain a HBW Bulimia nervosa: binge eating followed by purging /use of laxatives/diuretics/excessive exercise. Eating disorder not otherwise specified - disorders that do not meet criteria Anorexia & Bulimia

18. OBJECTIVES 1.Screen for the risk of developing eating disorders in young adults with and without T1DM. 2.To study its association with metabolic control (HbA1C)in T1DM patients.

19. YOUNG ADULTS DIABETES CLINIC Social worker Physician

20. METHODOLOGY TYPE 1 DIABETES CLINIC (18-43 yrs, no chronic, psych, not preg) (3 months) Case N=113 T1DM patients Control N=61 Age-gender matched non- diabetes 1. Anthropometry 2. EAT 26 - Eating Attitude test 3. HbA1C (HPLC) Approval -IRB of Hospital(IRB Min. No. 9547 dated 22.07.2015) Informed consent

21. EATING ATTITUDE TEST 26 Garner et al 1982 26 questions-related to eating attitudes Economical screening tool –standardised & validated, used to detect the risk of eating disorders Pertain to dieting, bulimia, preoccupation and oral control The patient responds- always, usually, often, sometimes, rarely or never- score is given Score > than 20, indicates a risk of developing eating disorders…need to be referred to a professional

22. Sample questions EAT 26….  Are you terrified of being overweight?  Avoid eating when hungry?  Find myself preoccupied with food?  Have gone on eating binges where I feel that I may not be able to stop  Cut my food into small pieces  Aware of the calorie content of my food…..  Vomit after I have eaten  Feel extremely guilty after eating….  Eat diet foods..  Engage in dieting behaviour…  Use laxatives, diuretics, diet pills, resort to purging to lose weight..  Exercise for more than 60 minutes per day  Lost 20 pounds or more in the last 6 months

23. Results: Characteristics of subjects T1DM Patients Age: 24+ 6.2 years BMI: 21.1 + 3.2 Duration: 9.1 + 7.2 years Mean HbA1C= 9.1 + 2.7% Regularity in insulin: 94.8% Insulin regime: – Split mix 75.4% – Basal bolus: 24.6% Non-diabetes Age- 26 + 5.1years BMI: 23.5 + 4.8 (p=0.001) Mean HbA1C < 5.7

24. TIDM RISK OF DEVELOPING EATING DISORDERS chi-square test: p=0.000; CI-0.49 to -0.29; ORR= 38.5

25. Eating disorder & Duration of Diabetes Chi-square test : p=0.013, ORR = 11.03, 95% CI= 1.4, 87.1

26. Risk of developing eating disorder Not associated with X BMI X Gender X Insulin Regimes

27. DISCUSSION High Risk group: Meta-analysis of 13 studies showed higher risk in TIDM (1) BMI: Neumark-Sztainer et al.,., found inconsistent associations -BMI and Eating Disorders (2)..in line HbA1C : – Colton et al., reported that metabolic control was not related to eating behaviour – Jones et al., Pinhas-Hamiel et al.,- mean HbA 1 C was higher in diabetes subjects with Eating Disorders Insulin medication: Neumark-Sztainer et al., found irregularity

28. References 1.Neumark-Sztainer D, Patterson J, Mellin A, Ackard DM, Utter J, Story M, et al. Weight Control Practices and Disordered Eating Behaviors Among Adolescent Females and Males With Type 1 Diabetes Associations with sociodemographics, weight concerns, familial factors, and metabolic outcomes. Diabetes Care. 2002;25(8):1289–96. 2.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. 2000;320(7249):1563–6. 3.Garner DM, Olmsted MP, Bohr Y, Garfinkel PE. The eating attitudes test: psychometric features and clinical correlates. Psychol Med. 1982 Nov;12(4):871–8. 4.Colton P, Olmsted M, Daneman D, Rydall A, Rodin G. Disturbed Eating Behavior and Eating Disorders in Preteen and Early Teenage Girls With Type 1 Diabetes A case-controlled study. Diabetes Care. 2004;27(7):1654–9. 5.Pinhas-Hamiel O, Hamiel U, Levy-Shraga Y. Eating disorders in adolescents with type 1 diabetes: Challenges in diagnosis and treatment. World J Diabetes. 2015 Apr 15;6(3):517– 26. 6.American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders [Internet]. Fifth Edition. American Psychiatric Association; 2013 [

29. Limitation of the study  This is a short term study…..  A Long term study is required to identify the time of initiation of Eating Disorder so that intervention can be initiated at an early stage thereby delay onset of diabetes complications.

30. Conclusion Diabetes team – maintain high index of suspicion in managing T1DM patients. Timely intervention by MH professional - routine hospital visits - identify this disorder and correct it. This will enable glycaemic control, reducing the incidence of diabetes related complications Further research is needed to study its prevalence in other types of diabetes conditions.

31. ACKNOWLEDGEMENT-DIABETES CARE TEAM UGC & IRB FUNDING THE PROJECT

32. THANKYOU VELLORE FORT, Tamil Nadu, S India THE SITE WHERE THE FIRST INDIAN FREEDOM STRUGGLE INITIATED