Bright Futures from the AAP (American Academy of Pediatrics) are available for free online. From the AAP website…

The centerpiece of the Bright Futures program, the guidelines, provide child health promotion information and guidance for health professionals from pediatricians to public health officials to school nurses.

The Bright Futures Guidelines can help you be prepared for visits with parents and children. Organized for quick, easy access to the information you want.

We had a longer spring then usual with bearable temperatures and a surprising lack of humidity - ah - it was so nice! But it is now officially summertime in St. Louis with the telltale signs… daily temperatures in the 90’s and higher and the kind of humidity that feels like a impenetrable wall. According to the CDC,

“Those at greatest risk for heat-related illness include infants and children up to four years of age…”

So check out these resources to update yourself on how to handle the extreme heat of summertime in St. Louis…

CDC:Frequently Asked Questions (FAQ) About Extreme Heat

NYT: A Common Symptom of Heat Illness: Denial

Child Care Weather Watch: When is it okay to play outside and for how long? Check out this great chart from the Iowa Department of Public Health.

Snakes and Insects

And since folks are getting out and about, here are resources on snake and insect bites…

Guidelines - Venomous Snakebites in the United States: Management Review and Update

Common Spider Bites

Practical Guide to Anaphylaxis

Poisonous Plants

Finally, don’t forget to watch out for…

Poison ivy, poison sumac, and poison oak

Guidelines of care for atopic dermatitis

What is the latest on EBP? Check out these recent articles…

1: BMJ. 2008 Apr 26;336(7650):924-6.

GRADE: an emerging consensus on rating quality of evidence and strength of

recommendations.

Guyatt GH, Oxman AD, Vist GE, Kunz R, Falck-Ytter Y, Alonso-Coello P, Schünemann
HJ; GRADE Working Group.

Collaborators: Alderson P, Alonso-Coello P, Andrews J, Atkins D, Bastian H, de
Beer H, Brozek J, Cluzeau F, Craig J, Djulbegovic B, Falck-Ytter Y, Fervers B,
Flottorp S, Glasziou P, Guyatt G, Harbour R, Haugh M, Helfand M, Helfand M,
Jaeschke R, Jones K, Kunnamo I, Kunz R, Liberati A, Marzo M, Mason J, Mrukovics
J, Norris S, Oxman A, Robinson V, Schünemann H, Tan Torres T, Tovey D, Tugwell P,
Tuut M, Varonen H, Vist G, Wittington C, Williams J, Woodcock J.

Department of Clinical Epidemiology and Biostatistics, McMaster University,
Hamilton, ON, Canada L8N 3Z5. guyatt@mcmaster.ca

PMID: 18436948 [PubMed - indexed for MEDLINE]

2: Medsurg Nurs. 2008 Feb;17(1):55-60.

Nurse knowledge, skills, and attitudes related to evidence-based practice: before

and after organizational supports.

Munroe D, Duffy P, Fisher C.

School of Nursing, Northern Illinois University, DeKalb, IL, USA.

Publication Types:
Evaluation Studies

PMID: 18429543 [PubMed - indexed for MEDLINE]

3: J Contin Educ Nurs. 2008 Apr;39(4):166-72.

Nurses reclaiming ownership of their practice: implementation of an

evidence-based practice model and process.

Reavy K, Tavernier S.

Boise State University, Department of Nursing, Boise, Idaho 83725-1840, USA.

This article describes a new model and process to implement evidence-based
practice. This model builds on concepts from the Iowa Model of Evidence-Based
Practice, the Stetler model, and Rosswurm and Larrabee's model. The new model
focuses on the centrality and involvement of staff nurses in making
evidence-based practice clinical changes. Two figures illustrate the model and
the implementation process. A detailed case study based on the model is included.
Barriers identified in the literature review are addressed in the case study.
Implementation of this model creates opportunities for staff nurses to recognize
ownership of their practice and their role in changing the practice setting to a
culture of evidence-based practice.

PMID: 18429370 [PubMed - indexed for MEDLINE]

4: J Contin Educ Nurs. 2008 Mar;39(3):105-9; quiz 110-1.

Increasing understanding of nursing research for general duty nurses: an

experiential strategy.

Sawatzky-Dickson DM, Clarke DE.

Health Sciences Centre, Winnipeg, Manitoba, Canada.

Misconceptions and trepidation about research abound among practicing nurses.
However, in light of the movement toward increasing accountability to consumers
and the concurrent drive toward evidence-based practice, the need for nursing
research can no longer be ignored. Innovative approaches to augment nurses'
training and education in research and evidence-based practice must be
incorporated into continuing education programs. The Nursing Research and
Evidence-Based Practice Committee of a large tertiary care teaching hospital in
Winnipeg, Manitoba, Canada, developed a series of opportunities for staff nurses
to participate in research projects and have ongoing exposure to the steps in the
research process. The Great Canadian Cookie Experiment was an opportunity to
participate in quantitative research. Qualitative data from patients' thank you
cards were analyzed in an interactive fashion during luncheon seminars held
during Nursing Week in 2 subsequent years. A survey of nurses who participated in
the luncheon seminars indicated an overall increase in their knowledge about
qualitative research methods and an appreciation for participating in the process
of nursing research. Continued visibility of nursing research will contribute to
changing nurses' attitudes toward fostering an evidence-based approach to
clinical practice.

PMID: 18386697 [PubMed - indexed for MEDLINE]

5: Int J Nurs Terminol Classif. 2008 Jan-Mar;19(1):14-9.

An exemplar of the use of NNN language in developing evidence-based practice

guidelines.

Kautz DD, Van Horn ER.

University of North Carolina at Greensboro, NC, USA. ddkautz@uncg.edu

PURPOSE. To explore the use of standardized language, NNN, in the development of
evidence-based practice (EBP). DATA SOURCES. Published research and texts on
family interventions, nursing diagnoses (NANDA-I), nursing interventions (NIC),
and nursing outcomes (NOC). DATA ANALYSIS. Research literature was summarized and
synthesized to determine levels of evidence for the NIC intervention Family
Integrity Promotion. CONCLUSIONS. The authors advocate that a "standards of
practice" category of levels of evidence be adopted for interventions not
amenable to randomized controlled trials or for which a body of research has not
been developed. Priorities for nursing family intervention research are
identified. IMPLICATIONS FOR NURSING PRACTICE. The use of NANDA-I nursing
diagnoses, NIC interventions, and NOC outcomes (NNN language) as research
frameworks will facilitate the development of EBP guidelines and the use of
appropriate outcome measures.

Publication Types:
Review

PMID: 18331480 [PubMed - indexed for MEDLINE]

6: J Nurs Manag. 2008 Apr;16(3):334-43.

Examining the knowledge, attitude and use of research by nurses.

Bonner A, Sando J.

School of Nursing Sciences, James Cook University, Cairns, Australia.
abonner@csu.edu.au

AIM: This study sought to determine the knowledge, attitudes and use of research
by nurses. BACKGROUND: There is little evidence about whether nurses are aware of
using research and how much research they use in their clinical practice. METHOD:
Using a descriptive design, 347 registered and Enrolled Nurses completed the
Edmonton Research Orientation Survey. RESULTS: Senior Nurse Managers were more
likely to have a positive attitude towards research, and completion of university
subjects on nursing research was significant in determining attitude and
knowledge of research. All nurses, regardless of position identified barriers to
performing research. CONCLUSION: Nurses require specific research education,
clinical nursing leadership and work environments conducive to ensure practice is
evidenced-based. IMPLICATIONS FOR NURSING MANAGEMENT: A positive attitude towards
research by Senior Nurse Managers has the potential to influence other nurses in
establishing an active nursing research culture and promote evidence-based
practice in the workplace.

Publication Types:
Research Support, Non-U.S. Gov't

PMID: 18324993 [PubMed - indexed for MEDLINE]

7: J Nurs Manag. 2008 Apr;16(3):327-33.

Increasing research evidence in practice: a possible role for the consultant

nurse.

Chummun H, Tiran D.

School of Health & Social Care, University of Greenwich, London, UK.
n.h.chummun@gre.ac.uk

AIMS: To determine the extent to which clinical nursing practice has adopted
research evidence. To identify barriers to the application of research findings
in practice and to propose ways of overcoming these barriers. BACKGROUND: Way
back in 1976, nursing and midwifery practice started adopting research evidence.
By 1990s, there was some transparency of research evidence in practice, but more
could have been done to widen its adoption. Many barriers were identified which
could hinder implementation of the evidence in practice, and the effort to remove
these remains weak. EVALUATION: 25 research articles from across Europe and
America were selected, and scrutinized, and recommendations analysed. FINDINGS:
Many clinical practitioners report a lack of time, ability and motivation to
appraise research reports and adopt findings in practice. The clinical
environment was not seen as research friendly as there were a general lack of
research activities and facilities locally. There was a clear lack of research
leadership in practice. IMPLICATION FOR NURSING MANAGEMENT: This paper reviewed
the research evidence from several published research papers and provides
consultant nurses with practical suggestions on how to enhance research evidence
application in their practice. It recommends how consultant nurses can make their
practice more research transparent by providing the required leadership, creating
a research-friendly organization, developing a clear research agenda and
facilitating staff develop a local research framework for reading research and
implementing research evidence in their practice.

Publication Types:
Review

PMID: 18324992 [PubMed - indexed for MEDLINE]

8: J Gen Intern Med. 2008 May;23(5):635-40. Epub 2008 Jan 5.

Tips for teachers of evidence-based medicine: understanding odds ratios and their

relationship to risk ratios.

Prasad K, Jaeschke R, Wyer P, Keitz S, Guyatt G; Evidence-Based Medicine Teaching
Tips Working Group.

Department of Neurology, Neurosciences Centre, All India Institute of Medical
Sciences, New Delhi, India.

Publication Types:
Review

PMID: 18181004 [PubMed - indexed for MEDLINE]

From the AACE (American Association of Clinical Endocrinologists) Patient Safety Exchange…

AACE Calls For New Standards for Safer Insulin Pump Use

2008-05-24 15:56:18
By: Richard Hellman, MD, FACP, FACE

AHRQ (Agency for Healthcare Research and Quality) has made the book Patient Safety and Quality: An Evidence-Based Handbook for Nurses available for free. You can download PDF’s of each chapter or order your choice of three printed volumes or a searchable CD-ROM. A print copy is already on its way to the SLCH Medical Library.

To start reading today, click here to access the chapters in PDF format. Click here for an order form to get your free print or CD-ROM copy.

Here is what AHRQ has to say…

Nurses play a vital role in improving the safety and quality of patient care-not only in the hospital or ambulatory treatment facility, but also of community-based care and the care performed by family members. Nurses need know what proven techniques and interventions they can use to enhance patient outcomes.

To address this need, the Agency for Healthcare Research and Quality (AHRQ), with additional funding from the Robert Wood Johnson Foundation, has prepared this comprehensive, 1,400-page, handbook for nurses on patient safety and quality-Patient Safety and Quality: An Evidence-Based Handbook for Nurses. (AHRQ Publication No. 08-0043).

Experts in the field reviewed the literature, and their contributions are grouped into these sections:

Patient Safety and Quality / Evidence-based Practice / Patient-centered Care / Working Conditions-Work Environment / Critical Opportunities for Patient Safety and Quality / Tools

From the RML News …

Evidence Based Medicine Resources - free and online!:

Need some way to understand Evidence Based Medicine just a little better? Check out these tutorials:

http://www.hsl.unc.edu/Services/Tutorials/EBM/welcome.htm

http://jeffline.tju.edu/Education/courses/informatics/activities/ebm_info.html

http://library.umassmed.edu/EBM/tutorials/index.cfm

http://www.usc.edu/hsc/nml/lib-services/tutorials/ebm.html

Taken from the April Issue of the Joint Commission’s Newsletter

Joint Commission Alert: Prevent pediatric medication errors

Medications specifically made for adults and administered to children in health care facilities are putting young patients at greater risk for drug errors, according to a Joint Commission alert issued to improve pediatric safety. The Joint Commission’s latest Sentinel Event Alert addresses pediatric medication errors, and urges greater attention to precautions such as medication standardization, improved medication identification and communication techniques, as well as the use of kilograms as the standard weight measurement to calculate proper dosages. Most of the harmful pediatric medication errors tracked during the past two years by U.S. Pharmacopeia involved either an improper dose or quantity, according to the Alert. Problems typically arise when hospitals and clinics are forced to prepare special volumes or concentrations because the drugs are formulated and packaged primarily for adults. The need to alter the original medication dosage requires a series of calculations and tasks that increase the chance for error.

To reduce the risk of pediatric medication errors, The Joint Commission’s Sentinel Event Alert suggests that health care organizations take a series of specific actions, including:

• Use the Joint Commission’s National Patient Safety Goals and Medication Management Standards to guide safe medication practices for pediatric patients.
• Weigh all pediatric patients in kilograms, which then becomes the standardized weight used for prescriptions, medical records and staff communication.
• Do not dispense or administer drugs classified as high risk until the patient has been weighed, unless it is an emergency situation.
• Require prescribers to write out how they arrived at the proper dosage, as dose per weight, so that the calculation can be double checked by a pharmacist, nurse or both.
• Use pediatric-specific medication formulations and concentrations when possible.

The Alert also encourages organizations to be open and transparent if an error occurs in order to facilitate learning so that future errors can be prevented; drug manufacturers to develop pediatric-specific formulations and to standardize labeling and packaging of all medications; and parents to seek out information and ask questions about their child’s medications and to repeat back instructions to health care professionals in order to avoid mix-ups. The Alert is available online. (Contact: Peter Angood, pangood@jointcommission.org)

The National Library of Medicine has a freely accessible database of drugs in lactation called LactMed.

You can search LactMed using either the common name or the medical name. For example, when I type in “Paxil” the first result I get is for “Paroxetine.”

A search will result in a summary of whether or not the drug can be taken while breastfeeding and why.

Each entry also includes…

• Drug Levels
• Effects in Breastfed Infants
• Possible Effects on Lactation
• Alternate Drugs to Consider

As with any good reputable resource, a reference list of the studies the information is based on and the last time the information was updated is included at the end.

The following appeared in the most recent edition of The Appendix, newsletter of the Health Sciences Library University of Colorado Denver. These rules are freely available here. These are good, clear, and concise rules.

Ten Simple Rules
Ever wish you had that mythical grandfatherly (or grandmotherly) mentor, guiding you along the path to success in your career? Why not avail yourself of an online mentor who fits that mold?

The Public Library of Science (PLoS) has prepared a collection of easy-to-use, practical guides for graduate students and junior faculty just beginning their academic careers. The Ten Simple Rules Collection, created primarily by PLoS Computational Biology Editor-in-Chief Philip E. Bourne, offers short guides to topics including:

Ten Simple Rules for Graduate Students
Ten Simple Rules for Doing your Best Research
Ten Simple Rules for a Good Poster Presentation
Ten Simple Rules for Making Good Oral Presentations
Ten Simple Rules for a Successful Collaboration
Ten Simple Rules for Selecting a Postdoctoral Position
Ten Simple Rules for Reviewers
Ten Simple Rules for Getting Grants
Ten Simple Rules for Getting Published

A seasoned researcher, Bourne has firsthand knowledge of the interpersonal and professional skills required to successfully compete for grants and take research from inspiration to publication. Benefit from his wisdom via the Ten Simple Rules collection. Struggle less and enjoy the trip to the top of your field with Bourne’s sage advice!

While the phrase “diabulimia” may be relatively new, reducing or omitting insulin intake to lose weight is not. I have included review articles, excerpts from books, and other articles.

Books…

Nelson Textbook of Pediatrics, 18th ed.
Section 6 - Diabetes Mellitus In Children - Chapter 590 - Diabetes Mellitus

EATING DISORDERS.

Treatment of T1DM involves constant monitoring of food intake. In addition, improved glycemic control is commonly associated with increased weight gain. In adolescent females, these two factors, along with individual, familial, and socioeconomic factors, can lead to an increased incidence of both nonspecific and specific eating disorders, which can disrupt glycemic control and increase the risk of long-term complications. Eating disorders and subthreshold eating disorders are almost twice as common in adolescent females with T1DM as in their nondiabetic peers. The reports of the frequencies of specific (anorexia or bulimia nervosa) eating disorders vary from 1% to 6.9% among female patients with T1DM. The prevalence of nonspecific and subthreshold eating disorders is 9% and 14%, respectively. About 11% of T1DM adolescent females take less insulin than prescribed in order to lose weight. Among adolescent females with an eating disorder, about 42% of patients misuse insulin, whereas the estimates of insulin misuse prevalence in subthreshold and nondisordered eating groups are 18% and 6%, respectively. While there is little information regarding the prevalence of eating disorders among male adolescents with T1DM, available data suggest normal eating attitudes in most. Among healthy adolescent males who participate in wrestling, however, the drive to lose weight has led to the seasonal, transient development of abnormal eating attitudes and behaviors, which may lead to insulin dose omission in order to lose weight.

When behavioral/psychological problems and/or eating disorders are assumed to be responsible for poor compliance with the medical regimen, referral for psychological evaluation and management is indicated. Children and adolescents with injection phobia and fear of self-testing can be counseled by a trained behavioral therapist and benefit from such techniques as desensitization and biofeedback to attenuate pain sensation and psychological distress associated these procedures. Behavioral therapists and psychologists usually form part of the pediatric diabetes team in most centers and can help assess and manage emotional and behavioral disorders in diabetic children.

Psychiatric Secrets, 2nd ed.
Chapter 74 - PSYCHOLOGICAL PERSPECTIVES IN THE CARE OF PATIENTS WITH DIABETES MELLITUS

21. Are eating disorders common in patients with diabetes?

Available studies do not answer this question clearly. Given its considerable requirements for changes in diet, diabetes mellitus, especially type I, may pose a special risk for the development of eating disorders. Diabetes in the population at greatest risk of eating disorders—women aged 15–35 years—may precipitate eating disturbances. Some evidence suggests increased rates of anorexia nervosa and bulimia in young women with diabetes. Ideals of body weight, which lead women to strive for weight loss, have problematic consequences in patients with diabetes. Polonsky and colleagues have shown that 30% of women with type I diabetes across the adolescent and adult age range acknowledged at least some omission of insulin and that 9% of all women acknowledged frequent omission of insulin. As expected, omission occurred even more commonly in women aged 15–30, but was found even in older women.

Binging and purging typically are experienced as shameful and may be hidden. Because of the likelihood of underreporting, current rates may underestimate the frequency of insulin omission. A significant minority of women who acknowledge omitting insulin do so explicitly to lose weight. Omission of insulin to lose weight is associated with a high level of psychopathology and is linked to significant problems with glycemic control. A history of eating disorder is also predictive of early development of retinopathy. Such findings underline the importance of identifying possible problems with body weight ideals and their association with habits of self-care.

Many patients with diabetes do not fully develop an eating disorder, although they discover the “merits” of occasional insulin underuse to control weight. Such patients, who do not meet threshold for diagnosis, may be the most difficult to identify, yet they represent an important high-risk group.

22. What are special considerations for the treatment of diabetic patients with eating disorders?

The treatment of eating disorders and associated conceptions of body weight often is difficult and time-consuming. Physician and patient may find themselves struggling to agree on goals for treatment. Thus, eating-related problems are particularly fruitful areas for collaborative models of treatment and for identifying specific areas of change that the patient is prepared to address.

The main problem is underuse of self-administered insulin as a method of “purging.” These patients fear weight gain, and underdosing with insulin becomes the preferred method of regulating weight. Underdosing may be present without other methods of purging. The identification of this form of eating disorder may require repeated questioning in a nonjudgmental manner. The clinician may uncover such problems only when the patient is sufficiently comfortable and senses that she will not be chastised.

The water-retaining effects of insulin complicate the problem. Reinsulinization may require considerable negotiation between patient and physician. The patient often does not differentiate between sources of weight gain or body size change. A 10-pound weight loss is a 10-pound weight loss, and a 10-pound weight gain is a 10-pound weight gain, whether due to changes in water volume, fat stores, or muscle mass. Thus reinsulinization accompanied by rapid weight gain and overt edema may be a terrifying experience for patients with intense beliefs about excessive weight.

23. Give an example of how a diabetic patient with an eating disorder may require special management.

A 23-year-old woman presented with bulimia that included binge eating and extensive underdosing with insulin. When hospitalized because of diabetic ketoacidosis and restarted on insulin, she rapidly regained the weight lost through dehydration and experienced pitting edema of the ankles. She became increasingly depressed and panicked by the weight gain to the extent that she requested a lower dose of insulin to control the terrifying spiral of weight. Despite careful explanation about the source of added weight, the patient could not differentiate between water gain and gain in fat stores. Thus, as part of the treatment plan, the dose of insulin was lowered and gradually increased to an optimal level. Hospitalization was extended until her weight stabilized; patient compliance could be relied on only after the threat of continuing weight gain from fluid retention disappeared.

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Review articles:

1: Postgrad Med. 2001 Apr;109(4):67-9, 73-4.
Eating disorders in adolescents with type 1 diabetes. A closer look at a complicated condition.
Hoffman RP.
Department of Pediatrics, Children’s Hospital and Ohio State University College of Medicine and Public Health, Columbus, USA. hoffmanr@pediatrics.ohio-state.edu

The cultural drive to be thin can lead to eating disorders in many women and girls. In adolescent females with diabetes, the increased focus on eating and the weight gain associated with good glycemic control likely increase their susceptibility to abnormal eating. It is clear that nonspecified and subthreshold eating disorders, and possibly bulimia and anorexia, are more common in this group of patients. Good nutritional counseling to help patients avoid weight gain and family counseling to improve communication between patients and their families may help decrease this risk. Intentional insulin omission is a frequent means of preventing weight gain or increasing weight loss in adolescent females with type 1 diabetes. Eating disorders should be suspected in patients with recurrent diabetic ketoacidosis or poor glycemic control that is resistant to attempts at improvement. Treatment includes decreasing dietary restraint, promoting healthy eating, and either psychiatric counseling or psychologic intervention, or both.

PMID: 11317470 [PubMed - indexed for MEDLINE]

2. Psychosomatics. 1998 May-Jun;39(3):233-43.
Eating disorders and insulin-dependent diabetes mellitus.
Crow SJ, Keel PK, Kendall D.
Department of Psychiatry, University of Minnesota, Minneapolis 55455, USA.

The eating disorders anorexia nervosa and bulimia nervosa have been reported to occur in Type I diabetes mellitus. Although prevalence estimates vary, the most rigorous studies yield rates similar to the population at large. Intentional insulin omission is more common, especially in young diabetic women, and at times may indicate an eating disorder in Type I diabetic patients. Both diagnosable eating disorders and intentional insulin omission are associated with worse glycemic control and higher rates of secondary diabetic complications. Recognition of these conditions, followed by carefully coordinated treatment involving both diabetes care providers and mental health providers, is necessary to improve treatment outcome.

Publication Types:

• Research Support, Non-U.S. Gov’t
• Research Support, U.S. Gov’t, P.H.S.
• Review

PMID: 9664770 [PubMed - indexed for MEDLINE]

3. Nurs Clin North Am. 1991 Sep;26(3):707-13.
Eating disorders as a special problem for persons with insulin-dependent diabetes mellitus.
Krakoff DB.
Ohio State University Hospitals, Department of Internal Medicine, Columbus.

Diabetes and eating disorders can be a deadly combination. Patients may omit or reduce their insulin dosages, which will induce glycosuria. Counseling and behavior modification are essential to prevent the development of complications such as DKA, frequent hypoglycemia, and the early onset of chronic complications. Diabetes education and insulin regulation must be combined with an interdisciplinary team approach to correct maladaptive coping mechanisms.

PMID: 1891403 [PubMed - indexed for MEDLINE]

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Some other articles of interest…

1: Nephrol News Issues. 2007 Oct;21(11):36, 38.
‘Diabulimia’ a growing problem among diabetic girls.
Yan L.

Publication Types:

• Case Reports

PMID: 17970504 [PubMed - indexed for MEDLINE]

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2: Psychosomatics. 2005 Jan-Feb;46(1):11-8.
Personality factors and disordered eating in young women with type 1 diabetes mellitus.
Pollock-BarZiv SM, Davis C.
Department of Kinesiology and Health Science, Faculty of Graduate Studies, York University/University Health Network. s.pollock.barziv@utoronto.caThe authors examined the association between the presence of personality variables implicated in the pathogenesis of eating disorders and the presence of eating disorder symptoms in 51 women with type 1 diabetes. Subjects were assessed with interview instruments and self-report questionnaires, including scales measuring eating disorder symptoms, borderline personality characteristics, and perfectionism. Fourteen subjects displayed moderate to severe eating disorder symptoms. Perfectionism was related to attitudinal aspects of eating disorders (e.g., weight preoccupation), and borderline personality characteristics were related to disordered behaviors (e.g., insulin omission) and poor glycemic control. The results suggest that personality factors are related to disordered eating and poor glycemic control in diabetic women.

PMID: 15765816 [PubMed - indexed for MEDLINE]

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3: Diabetes Care. 2002 Sep;25(9):1571-5.
Classification of type 1 diabetic females with bulimia nervosa into subgroups according to purging behavior.
Takii M, Uchigata Y, Nozaki T, Nishikata H, Kawai K, Komaki G, Iwamoto Y, Kubok C.
Department of Psychosomatic Medicine, Graduate School of Medicine, Kyushu University, Fukuoka, Japan. takii@cephal.med.kyushu-u.ac.jpOBJECTIVE: To classify type 1 diabetic females with bulimia nervosa (BN) by type of inappropriate compensatory behavior in order to prevent weight gain (ICB) and to investigate the group differences. RESEARCH DESIGN AND METHODS: Type 1 diabetic females with BN, diagnosed by structured diagnostic interview based on DSM-IV (Diagnostic and Statistical Manual of Mental Disorders, 4th ed.) criteria, were classified by type of ICB as follows: 1) only severe insulin omission as an ICB (BN-I) (n = 22), 2) both severe insulin omission and self-induced vomiting and/or laxative abuse (BN-IP) (n = 22), or 3) no insulin omission but another ICB (BN-NI) (n = 11). The clinical characteristics of these three groups and a binge-eating disorder (BED) group (n = 24) were compared. RESULTS: The BN-IP and BN-I groups had the highest HbA(1c) levels. The BN-IP group had the highest rates of diabetic neuropathy, retinopathy, and nephropathy. The BN-NI group had the second highest rates of neuropathy and retinopathy. The BN-IP group had the highest frequencies of diabetes- and ketoacidosis-related hospital admissions, and the BN-I group had the second highest frequencies. The BN-NI group showed the highest scores on psychological tests related to depression, anxiety, eating disorder psychopathology, and perfectionism. The BN-NI group had the highest rate of history of visits to a psychiatrist, and the BN-IP group had the second highest history. CONCLUSIONS: Type 1 diabetic females with BN seem not to be homogenous and can be classified into three distinctive subgroups by type of ICB. Individuals with BN-IP had the most severe problems with both medical and psychological/behavioral aspects. Individuals with BN-NI manifested the highest psychological distress. The BN-I group had comparatively mild distress despite having the poorest metabolic control. Each BN group manifested more severe pathology than the BED group.Publication Types:

• Research Support, Non-U.S. Gov’t

PMID: 12196429 [PubMed - indexed for MEDLINE]

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4: J Psychosom Res. 1999 Sep;47(3):221-31.
Differences between bulimia nervosa and binge-eating disorder in females with type 1 diabetes: the important role of insulin omission.
Takii M, Komaki G, Uchigata Y, Maeda M, Omori Y, Kubo C.
Department of Psychosomatic Medicine, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan. takii@cephal.med.kyushu-u.ac.jpThis study explored the differences between bulimia nervosa (”BN,” n=22) and binge-eating disorder (”BED,” n=11) in type 1 diabetic females and the factors most predictive of poor glycemic control in patients suffering from these disorders. These two groups and a control group without eating disorders (n=32) were compared across a number of demographic, psychological, and medical variables. BN manifested significantly more severe disturbances related to eating disorders, depression, anxiety, a higher rate of co-occurring mental disorders, and poorer psychosocial functioning compared with BED. BN also showed poorer glycemic control. Multivariate analysis indicated that higher serum glycosylated hemoglobin (HbA1c) levels were most associated with the presence of severe insulin omission in type 1 diabetic females with binge eating. Clinicians may be able to determine the psychological/medical severity of illness in these patients by identifying the presence of compensatory behaviors to prevent weight gain such as severe insulin omission, as described in the DSM-IV.

PMID: 10576471 [PubMed - indexed for MEDLINE]

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5: Diabetes Care. 1999 Jul;22(7):1221-4.
Hypersensitivity to regular and intermediate, but not to crystallized, insulin as an aggravation factor for underlying bulimia nervosa in a patient with type 1 diabetes.
Itoh M, Uchimura K, Makino M, Kobayashi T, Kakizawa H, Nagata M, Fujiwara K, Kato S, Itoh Y, Nagasaka A.Publication Types:

• Case Reports
• Letter

PMID: 10388999 [PubMed - indexed for MEDLINE]

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6. Diabetes Care. 1998 Jul;21(7):1110-6.
Comorbidity of diabetes and eating disorders. Does diabetes control reflect disturbed eating behavior?
Herpertz S, Albus C, Wagener R, Kocnar M, Wagner R, Henning A, Best F, Foerster H, Schulze Schleppinghoff B, Thomas W, Köhle K, Mann K, Senf W.
Clinic of Psychotherapy and Psychosomatics, University of Essen, Germany. stephan.herpertz@uni-essen.deOBJECTIVE: This multicenter study was designed to explore the prevalence of clinical and subclinical eating disorders (EDs), the extent of intentional omission of insulin and oral antidiabetic agents, and its relationship to glycemic control in an inpatient and outpatient population of men and women with type 1 and type 2 diabetes. RESEARCH DESIGN AND METHODS: Data have been collected from 12 diabetes medical centers in two German cities. In a questionnaire and interview-based study, a sample of male and female patients (n = 341 type 1, n = 322 type 2) was assessed for the following eating disorders: anorexia nervosa, bulimia nervosa, binge eating disorder, and eating disorder not otherwise specified. For lack of interview data of several patients meeting the screening criteria, prevalence ranges were calculated. RESULTS: The overall prevalence range of current EDs was 5.9-8.0% (lifetime prevalence 10.3-14.0%). When patients were stratified according to type 1 and type 2 diabetes, there was no difference in prevalence of EDs. However, the distribution of the EDs was different in both types of diabetes, with a predominance of binge eating disorder in the type 2 diabetes sample. Type 1 (5.9%) and type 2 (2.2%) diabetic patients reported deliberate omission of hyperglycemic drugs (insulin or oral agents) in order to lose weight. Compared with control subjects, neither the presence of EDs nor insulin omission influenced diabetic control. CONCLUSIONS: There seems to be no difference in prevalence rates of EDs in both types of diabetes; however, distribution of EDs is different. The findings suggest that neither EDs nor insulin omission are necessarily associated with poor control of glycemia. Binge eating disorder seems to precede type 2 diabetes in most patients and could be one of the causes of obesity that often precedes type 2 diabetes.Publication Types:

• Clinical Trial
• Comparative Study
• Multicenter Study
• Research Support, Non-U.S. Gov’t

PMID: 9653604 [PubMed - indexed for MEDLINE]

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7: Eur J Clin Nutr. 1997 Jul;51(7):462-6.
Women with insulin-dependent diabetes mellitus (IDDM) complicated by eating disorders are at risk for exacerbated alterations in lipid metabolism.
Affenito SG, Lammi-Keefe CJ, Vogel S, Backstrand JR, Welch GW, Adams, CH.
Department of Nutritional Sciences, University of Connecticut, Storrs 06269, USA.OBJECTIVE: To examine lipid parameters that are affected in women with insulin-dependent diabetes mellitus (IDDM) who engaged in disordered eating behaviours. DESIGN: Randomized, unmatched. SETTING: Tertiary care. SUBJECTS: Ninety women (18-46 y) with IDDM. INTERVENTIONS: Classification of subjects based on severity of eating disorder: clinical (n = 14), subclinical (n = 13) and control (n = 63). Blood was analysed for glycosylated haemoglobin (HbA1c) and serum for triglycerides and cholesterol. Carotenoid and tocopherol concentrations were analysed by high performance liquid chromatography (HPLC). Dietary intake was assessed by the National Cancer Institute food frequency questionnaire. RESULTS: HbA1c was significantly increased im women demonstrating clinical and subclinical symptoms compared to control (10.4 +/- 2.6, 10.0 +/- 1.5 and 8.3 +/- 1.6%, respectively, P < 0.05). Triglycerides concentrations were significantly increased in women with subclinical eating disorders compared to controls. In women who intentionally omitted or reduced insulin, triglyceride cholesterol and HbA1c were significantly increased compared to controls. Women with IDDM and eating disorders who exhibited bulimic behaviours consumed significantly more energy, total fat and cholesterol compared to controls and women with eating disorders who were restrained eaters. CONCLUSION: While IDDM is known to perturb lipid metabolism, these data demonstrate that eating disorders, in combination with IDDM, results in additional alterations in lipid metabolism.Publication Types:

• Clinical Trial
• Randomized Controlled Trial
• Research Support, Non-U.S. Gov’t
• Research Support, U.S. Gov’t, P.H.S.

PMID: 9234029 [PubMed - indexed for MEDLINE]

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8. Diabetes Care. 1997 Feb;20(2):182-4.
Subclinical and clinical eating disorders in IDDM negatively affect metabolic control.
Affenito SG, Backstrand JR, Welch GW, Lammi-Keefe CJ, Rodriguez, NR, Adams, CH.
Department of Nutritional Sciences, University of Connecticut, Storrs 06269, USA. affenito@uconnvm.uconn.eduOBJECTIVE: To characterize the relationship of subclinical and clinical eating disorders to HbA1c values in women with IDDM. RESEARCH DESIGN AND METHODS: Ninety women with IDDM (18-46 years of age) were recruited from diabetes clinics throughout Connecticut and Massachusetts. Subjects were categorized into one of three groups according to the Diagnostic Statistical Manual of Mental Disorders (DSM-III-R) criteria for eating disorders as follows: the clinical group (n = 14), the subclinical group (partially fulfilling the diagnostic criteria; n = 13), and the control group (n = 63). Group differences in the degree of dietary restraint, binge eating, and bulimic behaviors and weight, shape, and eating concerns were assessed with the Eating Disorder Examination (EDE) and the Bulimia Test Revised (BULIT-R). RESULTS: Women with subclinical and clinical eating disorders had clinically elevated HbA1c results and more diabetes-related complications, compared with the control subjects. The severity of bulimic behaviors, weight concerns, reduced BMI, and decreased frequency of blood glucose monitoring were associated with elevated HbA1c. CONCLUSIONS: HbA1c may have clinical utility in the identification of eating disorder behavior in females with IDDM. Health care professionals should be aware of the potent effect of subclinical and clinical eating behaviors including insulin misuse in weight-conscious women with IDDM who have poor glycemic control.Publication Types:

• Research Support, Non-U.S. Gov’t
• Research Support, U.S. Gov’t, P.H.S.

PMID: 9118770 [PubMed - indexed for MEDLINE]

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9: Compr Psychiatry. 1990 May-Jun;31(3):205-10.
Insulin-dependent diabetes mellitus and eating disorders: a prevalence study.
Powers PS, Malone JI, Coovert DL, Schulman RG.
Department of Psychiatry, University of South Florida, Tampa.There have been numerous reports in the recent literature suggesting a relationship between diabetes mellitus and the eating disorders. In the current investigation, 97 pediatric diabetes patients were administered a modified version of the Eating Habits Questionnaire, which included items specific to diabetes mellitus based on DSM-III-R criteria. None of this sample were diagnosed as anorexic and only one patient was diagnosed as currently bulimic. Possible reasons for the higher prevalence rates reported for other samples are discussed.

PMID: 2187655 [PubMed - indexed for MEDLINE]

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10: Acta Psychiatr Scand. 1990 Mar;81(3):236-9.
Insulin sensitivity in patients with anorexia nervosa and bulimia.
Kiriike N, Nishiwaki S, Nagata T, Okuno Y, Yamada J, Tanaka S, Fujii A, Kawakita Y.
Department of Neuropsychiatry, Osaka City University Medical School, Japan.Insulin sensitivity was studied using the euglycemic insulin clamp technique in 5 female patients with anorexia nervosa and 4 females with bulimia. The results were compared with those of 15 male patients with non-insulin-dependent diabetes mellitus. Euglycemic insulin clamp is performed for 2 h using the Biostator, during which time insulin was infused at a rate of 0.77 mU kg-1 min-1. Fasting plasma glucose and immunoreactive insulin tended to be lower in patients with anorexia nervosa than in those with bulimia (69.8 +/- 6.7 vs 75.9 +/- 7.7 mg/dl, and 5.9 +/- 2.0 vs 9.8 +/- 3.4 U/ml). The mean metabolic clearance rate (MCR) was 9.2 +/- 3.9 ml kg-1 min-1 for patients with anorexia nervosa, 5.1 +/- 2.2 ml kg-1 min-1 for patients with bulimia, and 3.8 +/- 0.3 ml kg-1 min-1 for patients with diabetes mellitus. However, one anorectic had a significantly high MCR. One anorectic and 3 bulimics had a significantly low MCR. These results suggest that insulin sensitivity varied in patients with anorexia nervosa, whereas it tended to decrease in some patients with bulimia but not to the same degree as in patients with diabetes mellitus.

PMID: 2188478 [PubMed - indexed for MEDLINE]

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11: Am J Nurs. 1989 Apr;89(4):482-5.
Diabetes and bulimia. A deadly duo.
Kopeski LM.
University of Virginia Health Sciences Center, Charlottesville.PMID: 2705494 [PubMed - indexed for MEDLINE]