For those of you out there who routinely care for adolescent females with or without diabetes this next series of posts is for you. We will move through the global nature of eating disorders, body image and females, disordered eating in adolescents, and disordered eating in special populations. I am beginning the series at a place where it should in theory end, because this topic is one of the most critical to anyone who cares for an adolescent female with Type 1 diabetes (T1DM). These girls who have T1DM and DEB begin in pediatrics and end up with adult endocrinology when their complications begin to surface. For those of you who don’t care for this population in a specialty area, your knowledge about this phenomenon is even more critical, because you care for them in other places. School nurses, pediatric clinic nurses, pediatric urgent care nurses, women’s health nurses, public health nurses, …. ANY nurse…. this post is for you.
Background. Let’s build from the basics, Type 1 Diabetes (T1DM) is an autoimmune disease, prevalent in 19 of every 100,000 Americans under the age of 20 (1), where there is insufficient insulin for metabolic function. Specifically, β-cell function in the pancreas ceases secondary to destruction by T-cell mediated responses (2). Many genetic and environmental triggers play roles in development of T1DM, with peak age of diagnosis between 10 to 14 years old (3).
The control of blood glucose levels in diabetes is important to prevent the onset of both short and long-term complications. The ADA recommends that, as a sign of control, Hemoglobin A1C levels (HbA1C) be monitored quarterly with a goal of 7% or less (2). HbA1C levels, which correlate with average blood sugar readings over the previous 120 days, provide information about how well the medical regimen of the T1DM patient is working to control their blood glucose. Prolonged elevation of blood sugar levels leads to retinopathy, nephropathy, neuropathy, peripheral vascular, cardiovascular, and cerebrovascular disease (4,5).
Eating Disorders and Disordered Eating in Type 1 Diabetes. Eating disorders primarily affect young women and adolescents, being 3 times as high in lifetime prevalence among women than men (6). The mean age of onset of eating disorders ranges from 18 to 21, with some girls beginning as young as age 10 (6). Adolescent females with Type-1 diabetes have a two to four-fold higher incidence of eating disorders than their non-diabetic counterparts (7,8,9,10). More than just eating disorders, many girls engage in sub-clinical or disordered eating behavior (DEB). For diabetics, this becomes particularly problematic because their DEB of choice is insulin omission.
Insulin Omission. Insulin omission is a DEB weight loss method that is unique to adolescents with T1DM. Regardless of rates of actual eating disorders in general T1DM populations reported rates of insulin omission or dosage manipulation are high, between 14 to 73% (9, 10, 11, 12, 13, 14, 15, 16, 17, 18).
There is a significant risk for life threatening complications and mortality among DEB females with T1DM, where insulin omission is present (7, 19). The majority of research in T1DM females supports elevated HA1C levels in the presence either of eating disorder, insulin omission, or both. Insulin omission results in increased rates of diabetic ketoacidosis, hospitalizations for acute illness, nephropathy, retinopathy, neuropathy and premature death (9, 12, 15, 18, 19, 20, 21, 22, 23). Duration of insulin omission is the defining factor in rates and speed of development of nephropathy and retinopathy in T1DM females with eating disorders (17, 19). In essence, the girls with T1DM who omit insulin, regardless of eating disorder status, loose their eyes and kidneys at higher rates and more quickly than other T1DM adolescents with poor control.
Factors related to DEB in T1DM. There is a great deal of current research on factors related to DEB and prevalence rates. Factors strongly tied to DEB and insulin omission in T1DM adolescent females are: Body image (10, 21, 24, 25, 26, 29), elevated BMI (14, 21, 24), Depression (7, 17, 29), Self-esteem (21, 24), Feeling ineffective (25), Wishful thinking and emotional regulation (27), Diabetes management emotions (7, 28), Anxiety (7, 17), Negative family cohesion/communication (7, 17, 21), Maternal characteristics (14, 15, 26).
However, despite this mountain of research… no clinical guidelines for screening for this behavior, or even girls at risk for DEB and insulin omission, is non-existant. Further, no intervention research or recommendations have been made.
There is HOPE. Every good nurse knows that prevention is the key to any significant and costly illness. This is where we come in nurses. Now that we know the related factors, we can identify girls at risk for DEB in our practices and intervene on those factors. We can also look at simply screening for those who are high risk or engaging in this behavior in practice by two simple biological markers. It has been suggested that BMI and HgA1c level would be great biophysical screeners for this population (29). Further, RESEARCH on interventions and screening needs to be done, and who better to do that than nurses? The psychosocial, familial, and health care components of this complex phenomenon call for not only multidisciplinary research, but nursing to head such research teams. Are you ready to tackle this area nurses?
*Note: I am starting a pilot project to look at one intervention: Mothers and daughters, self-esteem, body image, and communication in high risk girls. Anyone want to join me?
References
1. National Institute Of Health. (2008, June ). National Diabetes Statistics, 2007. Retrieved August 11, 2009, from National Diabetes Information Clearinghouse Web site: http://diabetes.niddk.nih.gov/DM/PUBS/statistics/#d_allages
2. American Diabetes Association (2009). Executive Summary: Standards of medical care. Diabetes Care, 32(sup1), s6-s12. doi:10.2337/dc09-S006
3. Newhook, L., Curtis, J., Patterson, A., et al. (2004). High incidence of Type 1 Diabetes in the Avalon Peninsula, Newfoundland, Canada. Diabetes Care, 27(4), 885-888.
4. DCCT Writing Team (2003). Sustained effect of intensive treatment of type 1 diabetes mellitus on development and progression of diabetic nephropathy: the epidemiology of diabetes interventions and complications (EDIC) study. The Journal of the American Medical Association, 290(16), 2159-2167.
5. Martin, C., Albers, J., Waberski, B., et al. (2006). Neuropathy among the diabetes control and complications trial cohort 8 years after trial completion. Diabetes Care, 29(2), 340-344.
6. Hudson, J., Hiripi, E., Pope, H., & Kessler, R. (2007). The prevelance and correlates of eating disorders in the national comorbidity survey replication. Biological Psychiatry, 61, 348-358.
7. Goebel-fabbri, A., Fikkan, J., Frank, D., et al. (2008). Insulin restriction and associated morbidity and mortality in women with type 1 diabetes. Diabetes Care, 31(3), 415-419.
8. Jones, J., Lawsone, M., Daneman, D., et al. (2000). Eating disorders in adolescent females with and without type 1 diabetes: Cross sectional study. The British Medical Journal, 310(10), 1563-1566.
9. Nielsen, S. (2002). Eating disorders in females with type 1 diabetes: An update of a meta-analysis. European Eating Disorders in Review, 10(4), 241-254.
10. Pinar, R. (2005). Disordered eatingh behaviors among turkish adolescents with and without tyupe 1 diabetes. Journal of Pediatric Nursing, 20(5), 383-388.
11. Ackard, D., Neumark-Sztainer, D., Schmitz, K., et al. (2008). Disordered eating and body dissatisfaction in adolescents with type 1 diabetes and a population-based comparison sample: comparative prevalence and clinical implications. Pediatric Diabetes, 9(4 part-1), 312-319.
12. Crow , S., Keel, P., & Kendall, D. (1998). Eating disorders and insulin-dependent diabetes Mellitus. Psychometrics, 39(3), 233-243.
13. Daneman, D., Olmsted, M., & Ryall, A., et al., (1998). Eating disorders in young women with type 1 diabetes. Hormone Research, 50(sup1), 79-86.
14. Maharaj, S., Rodin, G., Olmsted, M., et al., (2003). Eating disturbances in girls with diabetes: the contribution of adolescent self-concept, maternal weight and shape concerns and mother-daughter relationships. Psychological Medicine, 33, 525-539.
15. Neumark-sztainer, D., Patterson, J., Mellin, A., et al., (2002). Weight control practices and disordered eating behaviors among adolescent females and males with type 1 diabetes. Diabetes Care, 25(8), 1289-1296.
16. Peveler, R., Bryden, K., Neil, A., et al., (2005). The relationship of disordered eating habits and attitudes to clinical outcomes in young adult females with type 1 diabetes. Diabetes Care, 28(1), 84-88
17. Takii, M., Komaki, G., Ugchigata, Y., et al., (1999). Differences between bulimia nervosa and binge-eating disorder in females with type 1 diabetes: The important role of insulin omission. Journal of Psychosomatic research, 47(3), 221-231.
18. Takii, M., Uchigata, Y., Nozaki, T., et al., (2002). Classification of type 1 diabetic females with bulimia nervosa into subgroups according to purging behavior. Diabetes Care, 25(9), 1571-1575.
19. Takii, M., Uchigata, Y., Tokunaga, S., et al., (2008). The duration of severe insulin omission is the factor most closely associated with the microvascular complications of type 1 diabetic females with eating disorders. International Journal of Eating Disorders, 41(3), 259-264.
20. Bryden, K., Neil, A., Mayou, R., et al., (1999). Eating habits, body weight, and insulin misuse. Diabetes Care, 22(12), 1956-1960.
21. Colton, P., Olmsted, M., Daneman, D., Ryadall, A., & Rodin, G. (2007). Natural history and predictors of disturbed eating behavior in girls with type 1 diabetes. Diabetic Medicine, 24, 424-429.
22. Goebel-fabbri, A., Fikkan, J., Frank, D., et al., (2008). Insulin restriction and associated morbidity and mortality in women with type 1 diabetes. Diabetes Care, 31(3), 415-419.
23. Nielsen, S., Emboerg, C., & Molback, A. (2002). Mortality in concurrent type 1 diabetes and anorexia nervosa. Diabetes Care, 25(2), 309-312.
24. Engstrom, I., Kroon, M., Arvidsson, C., et al. (1999). Eating disorders in adolescent girls with insulin-dependent diabetes mellitus: A population-based case-control study. Acta Paediatrics, 88, 175-180.
25. Kahn, Y., & Montgomery, A. (1996). Eating attitudes in young females with diabetes: Insulin omission identifies a vulnerable subgroup. The British Journal of Medical PSychology, 69, 343-353.
26. Kitchler, J., Foster, C., & Opipari-arrigan, L. (2008). The relationship between nebative communication and body image dissatsifaction in adolescent females with type 1 diabetes mellitus. Journal of Health Psychology, 13, 336-347.
27. Grylli, V., Wagner, G., Hafferl-Gattermayer, A., et al., (2005). Disturbing eating attitudes, coping styles, and subjective quality of life in adolescents with Type 1 diabetes. Journal of Psychosomatic Research, 59, 65-72.
28. Affiento, S., Backstrand, J., Lammi-Keefe, C., et al., (1997). Subclinical and clinical eating disorders in IDDM negatively affect metabolic control. Diabetes Care, 20(2), 182-184.
29. Olmsted, M., Colton, P., Daneman, D., Rydall, A., & Rodin, G. (2008). Predictions of the onset of disturbed eating behavior in adolescent girls with type 1 diabetes. Diabets Care, 31(10), 1978-1982.
I have attached the flier if any of you are interested in going to the Adolescent Health Conference sponsored by the Missouri Department of Health and Senior Services and the Missouri Nurses for Public Health. It looks to be a pretty good offering.
http://nursestory.files.wordpress.com/2010/01/adolescenthealthcaretrainingbrochure2010-1.pdf
Maybe I will see you there!
There is a great nursing leader you should check out, Dr. Maithe Enriquez. Dr. Enriquez was a pleasure to write about. Check out her mission, leadership and work at http://nursestory.com/nurse-leaders/maithe-eniquez-phd-rn-anp-the-whole-nursing-package/
Non-Nursing (well… o.k. maybe it is Nursing related): Movies you should watch over Christmas break
Students, faculty, nurses, and all other people…. You may have a day or two of down time this Holiday Season and my advice is. TAKE IT! Take a day off, in your pajamas, and relax. Do not clean the kitchen, do not go visit someone, do not go shopping or to a sale somewhere… just stay home and take a day off.
While you do that… watch a movie. These are a few I recommend that deal with one of the following: health care, changing the world, changing your view, or having your eyes opened. These are several of the most moving films I have ever seen, but don’t take my word for it (I am certainly no film critic and often am subjected to reruns of Phineas/Ferb and Spongebob). Watch one!
Schindler’s List – If you have not seen it, you should. It is one of the iconic movies of our generation. I took not only history away from it, but a feeling of purpose in my own life for causes I believe in.
Something The Lord Made - This HBO original film is very well done and speaks to relationships, judgment, critical thinking, racism, and science.
Lorenzo’s Oil – This 1992 drama depicts the real life struggle and quest for change of a family, regarding their son’s diagnosis and prognosis. The amazing work of Augusto Odone in finding a treatment for a fatal disease is literally unforgettable.
And the Band Played On – This very moving film from the late 1980’s highlights the AIDS epidemic in its earliest stages. It is a historical look at this disease that all people should be privy to.
Hotel Rwanda – I could go on and on about this film, but it speaks for itself. Courage, leadership, doing the right thing in the midst of Chaos are all present in the plot. For me, civil unrest, cultural views, and violence will never be the same.
The Boy in the Striped Pajamas – This very moving film, the only one in the group that is not a ‘true story’ but still worth the time to watch, shows the openness of children and the equality of human beings. Set in a WWII concentration camp, clear contrasts are made concerning human nature and goodness.
The Soloist – After watching this movie I simply had to sit alone for a while and absorb it. Mental illness, homelessness, and my own personal responsibility (or perception of) to both were glaringly present throughout the film.
I have started a new page where I will profile important, but perhaps little known nurse leaders. Woo hoo! I know you all were anxiously awaiting its arrival and it is here. The first post, about Dr. Carole Eldridge is up; http://wp.me/PeDIg-2T. Check back often to see updates or even to suggest a nurse leader that should be profiled.
Blogs as a Method of Undergraduate Health Care Education: Benefits to everyone (Examples of Student Webliographies)
Many undergraduate educators struggle with conveying two key concepts to their students: How to effectively communicate through written format and relevance of writing assignments. Likewise, many people who would benefit from access to students’ work cannot because access is restricted to the relationship between student and professor. Much of the hard work spent on undergraduate literature reviews, concept and theory overviews, evaluation of systems, case studies, community work, etc. is simply lost to the current formative and summative evaluation systems that higher learning has continued to use for centuries.
Blogs
Blogs offer a method for writing and critical thinking where students can begin to build portfolios of work, knowledge, and platforms that can benefit others through web connections. In a world where technology and information are changing rapidly, helping students to ‘publish’ without the constraints of time or the requirement of journal submission (many who won’t accept undergraduate work), blogs offer a way for students to disseminate what they know, ideas they have, or experiences in learning that might benefit the ones educating them. Not to forget that blogging expands their knowledge and use of social media.
Blogging also teaches students to write concisely (get to the point already) and clearly (a problem they often struggle with). One disadvantage to using blog assignments, as educators, is that ‘bleeding’ all over them with a red ink pin is difficult in web format. However, the resourceful instructor who edits can simply copy and paste and with the edition of track changes… and voila- you have feedback. Students also bear the disadvantage of their writing errors being accessible to the entire connected world, but this seems to be a motivator for good work. Below I offer a few tips, after piloting a class where I required the majority of journal writing to be in blog format. I have learned much in utilizing blogs to help educate and evaluate student work, and will continue to revise blogging assignments.
Tips for Teaching Through Blogging
1. The instructor needs to be very familiar with blogging platforms, design, and free access for students. This first recommendation is the most difficult at times. Many faculty are not familiar with blogging, how to go about designing a blog, where to get a free blog, or the intricacies of blog tool bars, dashboards, and simple tasks like creating active links within posts.You don’t need to know HTML code to work free blog creators such as WordPress or Blogger
2. The instructor needs to create a time to work with students on developing an initial blog. Whether you teach online or in a traditional seated class you need to set aside some class time (not extra work time for the students) to help them create a blog. Take them to the computer lab and help them sign in and navigate design, telling them advantages of having widgets or three columns, etc… If you teach in an asynchronous online format I would suggest audio recording along with a visual presentation (maybe you want to use Screencast or Slideshare to accomplish this… if your university doesn’t have a great format like WIMBA or Elluminate… however, Skype or TokBox work great as well).
3. Assign writing that is currently relevant to the student and the profession, but give them some freedom in choosing topics. If students find the writing assignment tedious, boring, or irrelevant to themselves they are not going to enjoy writing, nor will they continue blogging beyond your class; the idea is to help them create a medium that they can continue to write through long after your course is over.
4. Explain rules of etiquette in online communication, professionalism, and how taking up time and internet space with irrelevant words is irritating 
. A gentle but clear discussion with students about how naming fellow students, co-workers, employers, teachers, without permission is not professional writing. Likewise, ranting is not ideal in a course or professional blog. Create a grading rubric that addresses this as part of the final grade. Further, the world is full of useless words and distractions. Remind students that their blog should not be an addition to the junk and noise on the web, but a clear and concise offering that will contribute to the knowledge-base of their profession or to others who will read their blog. Grade them based on this aspect as well.
5. Support your students through promotion of their work. One of the best ways to spur on excellence is to support students work within other student circles, faculty, and professional groups of the students’ primary degree area. If you twitter, tout students’ work with links or shout outs. Present students’ work as part of accreditation visits, at conferences, and to other classes.When students know that others will be reading their work, with their name on it, they often are motivated to make corrections and to make their initial product of much higher quality.
Creating Webliographies
On a final topic note, blogs are a great way for sound webliographies on health care issues to be created. By creating webliographies students are forced to learn what are reliable and valid internet sources, creating knowledge they can transfer to others and their patients in a world full of incorrect information. They also create a single source for several reviewed internet resources on a single topic. Webliographies are great additions to student blogs and assist them in building sound knowledge on a single subject and begin their journey into being content experts or into specialization.
I have included some of my students’ blogs and webliographies below. Yes, typo’s grammatical errors, broken links, etc. are present, but for a first attempt at such an assignment and a pilot project (without them having the benefit of all the tips I have offered to you above) they have done fairly well. They have at the very least compiled valid resources for patients. Check them out and happy blogging!
Preventing Risks of Central Line Infections – http://stephaniern.wordpress.com/
Health Care DPOAs – http://mommycmsrn.wordpress.com/
Alzheimer’s Disease – http://movinonup09.wordpress.com/
Testosterone deficiency vs. Depression in men – http://scotchtwin18.wordpress.com/
Childhood Onset Schizophrenia – http://erjunky.wordpress.com/
Meningitis – http://rain029.wordpress.com/
Knee Replacement Recovery – http://orthonurse.wordpress.com/
I am so proud of them and their work. Good job Nurses. http://nursing.advanceweb.com/Editorial/Content/Editorial.aspx?CC=208098
