Cymru Wales

Overview of Current Eating Disorders Services in Wales for People with Type 1 Diabetes and Disordered Eating (T1DE)

Rachael Humphreys, All Wales Nurse Lead for Type 1 Diabetes and Eating Disorders (T1DE)

Type 1 Diabetes

Type 1 Diabetes is an auto-immune condition where the hormone, insulin, is destroyed resulting in a complete deficiency of insulin. Insulin is vital for life, stabilising blood glucose levels and allowing the body to use the glucose effectively for energy; without insulin people cannot survive. Managing Type 1 Diabetes is complex. People living with Type 1 Diabetes are on intensive regimes where insulin is replaced via multiple daily injections or continuous insulin pump therapy to stabilise blood glucose levels. From diagnosis, people living with Type 1 Diabetes, or their parents/carers in the case of paediatric patients, are expected to maintain stable blood glucose levels by matching food containing carbohydrate with the right amount of insulin, referred to as carbohydrate counting. From diagnosis people with Type 1 Diabetes have to take into account how much carbohydrate is in their food, what their blood glucose level is, whether they are about to undertake any activity, or if they are unwell, in order to make sensible decisions regarding the amount of insulin that they need. If they do not calculate this accurately, their blood glucose levels can fluctuate and this in turn requires further management. Their awareness of food, particularly carbohydrate which is their main source of glucose, is heightened and they are introduced to the concept of weighing food, numbers, accuracy, and perfectionism when it comes to maintaining glucose levels within range, counting carbohydrate accurately, and reaching a ‘target’ HbA1c.

Due to the complexities surrounding managing Type 1 Diabetes, people living with the condition are at an increased risk of anxiety and depression due to their loss, and lack of control, of their health (Nip et al.2019, Araia et al. 2020) This in turn increases their risk of developing Type 1 Disordered Eating (T1DE), a range of behaviour presentations that attempt to control weight (RCPSYCH 2022). It has been reported that eating disorders are twice as common in people with type 1 diabetes than without and presents in up to 30% of people with type 1 diabetes (Jones et al. 2000), and the use of insulin restriction as a purging behaviour gives rise to an increased rate of both acute and chronic diabetes complications (Pinhal-Hamiel 2015, Staite et al. 2018). Within children and young people with Type 1 Diabetes, 7% have a clinically significant eating disorder (Young et al. 2013). It is thought within diabetes services that far more people have experienced T1DE, or continue to experience T1DE, without recognition or a formal diagnosis.

According to the Royal College of Psychiatrists (RCPSYCH 2022) behaviour presentations in people with Type 1 Diabetes to control weight can include:

Insulin omission or the restriction of insulin
Restriction of food
Over-exercise
Self-Induced vomiting
Laxative or diuretic misuse
Medications used for thyroid/diabetes management may also be misused to reduce body weight
Insulin over-injection to cover binge eating or fear of acute complications associated with insulin omission

Insulin omission or the restriction of insulin for weight control purposes places patients at high risk of developing Diabetic Ketoacidosis, which can be life-threatening, and is associated with a three-fold increase in mortality and reduced quality of life (Staite et al. 2018, Goebbel-Fabri et al. 2008, Reveler and Fairburn 1992). The long-term complications of insulin omission or restriction include retinopathy, nephropathy, neuropathy which can lead to limb amputation, and heart disease. Insulin over-injection places patients at high risk of severe hypoglycaemia, which can result in unconsciousness and can be life-threatening. Where insulin omission or restriction is the dominant behaviour, re-introducing insulin and carbohydrate requires a careful and gradual approach to reduce the risk of decreasing glucose levels too quickly, which can in turn increase the risk of retinopathy and neuropathy (National Institute for Clinical Excellence 2017, RCPSYCH 2022).

Diagnosing T1DE is complex and RCPSYCH has proposed diagnostic criteria to assist healthcare professionals in identifying if the behaviour patterns are associated with T1DE, or if other diabetes-related factors may be mistaken for T1DE, for example difficulty accepting the diagnosis, diabetes distress, and disengagement from their diabetes service. It is important that health care professionals can differentiate and identify if concerns over body, weight and shape are dominant factors and be guided by the criteria proposed by RCPSYCH to ensure that patients receive the appropriate support and treatment.

People with Type 1 Diabetes who meet all three criteria for T1DE:

Intense fear of gaining weight, or body image concerns, or fear of insulin promoting weight gain
Recurrent inappropriate direct or indirect* restriction of insulin (and/or other compensatory behaviour**) to prevent weight gain
Presenting with a degree of insulin restriction, eating or compensatory behaviours, that cause at least one of the following:
Harm to health
Clinically significant diabetes distress
Impairment on daily functioning

*Indirect restriction of insulin refers to reduced insulin need/use due to significant carbohydrate restriction

**Dietary restriction, self-induced vomiting, laxative use, excessive exercise, over-use of thyroid hormones, over-use of diabetes medication believed to avoid weight gain or promote weight loss

Where there is concern of T1DE links with local eating disorder, mental health and diabetes teams is required – due to the complexity of T1DE both diabetes and eating disorder specialists need to work together with the patient to ensure appropriate treatment is provided. A shared-care model is recommended by RCPSYCH and NICE. Where hospital admission is required, collaborative working between the diabetes team, medical teams, mental health services, eating disorders service, and psychiatry is essential. There needs to be a collaborative approach in re-introducing insulin and carbohydrate, where insulin and/or carbohydrate has been omitted or restricted, with the aim being to prevent rapid weight gain associated with the re-introduction of insulin as well as reducing the risk of retinopathy and neuropathy (NICE 2017, RCPSYCH 2022). Close monitoring of patients with Type 1 Diabetes for hypoglycaemia, hyperglycaemia, Diabetic Ketoacidosis, glucose toxicity, and oedema is essential in managing their level of risk, dependent on their eating disorder behaviours, eg. Insulin/carbohydrate restriction, bulimia nervosa, binge-eating disorder (NICE 2017, RCPSYCH 2022)

It must be noted here that most patients with T1DE will have a normal weight and BMI considered within the healthy range and cannot be used as an identifying factor in diagnosing T1DE. This can be especially difficult when trying to refer to eating disorder services and the risk needs to focus on the criteria listed above, rather than low weight/low BMI.

Current Eating Disorder Services in Wales

In 2019, the then Minister for Health and Social Services, Vaughan Gething AC/AM, wrote to the Chief Executives of Health Boards following an independent review into Eating Disorders in Wales, with recommendations to improve services and outcomes for patients. The review, published in November 2018, recognised that there was a need for change, particularly in prevention and early identification and treatment of patients before they become severely unwell. The report identified that eating disorders services in Wales are significantly under-resourced and that significant investment was required to improve patient experience and outcomes.

The report reflected on the ‘greatly raised risks of dual disorders, such as Type 1 Diabetes and an eating disorder … and now services such as paediatric diabetes are beginning to recognise that an integrated approach between these services is needed’ (WAG, 2018, p7). The recommendations from this review are listed below:

The Welsh eating disorder and diabetes teams for both children and young people and for adults must develop national protocols to co-work with each other for patients who have both eating disorders and diabetes. There should be national leads in both eating disorders and diabetes services who can cooperate to develop training and awareness amongst staff in both systems, and to work particularly to identify and manage patients with diabetes who have disordered eating or early signs of eating disorders. Given the major diabetes-specific challenges and high medical risks involved in managing patients who have diabetes and eating disorders we recommend a national multidisciplinary subspecialist team within the national eating disorder service which has dual expertise in diabetes and eating disorders.

The Welsh Government should ensure that NICE guidelines for diabetes should be adhered to and that diabetes teams should have psychology input for their patients, who are skilled in identifying and managing disordered eating.

Since this report, the All Wales Diabetes Implementation Group has been established with an All Wales Project Lead for T1DE (3.5hrs/week) in post. The All-Wales clinical forum steering group was set up with representation from all health boards in the areas of paediatric and adult diabetes services, mental health services, and eating disorder services. Each health board have designated leads within their service to implement changes within their service, and consultation groups between diabetes and eating disorders services across the health boards are now established. There is still room for improvement – building team confidence in identifying T1DE is a priority, as well as agreed screening tools and referral to eating disorders services if a patient meeting the criteria for T1DE is identified. There can still be too much focus on weight and BMI and therefore discord in patients with T1DE meeting the threshold for eating disorders services. Recognition of the RCPSYCH proposed criteria is imperative in recognising the escalated risk this patient cohort presents with due to insulin omission and their significant risk of immediate harm and mortality.

In 2022, the first full-time adult diabetes specialist nurse was employed by SHED, Service for High risk Eating Disorders covering Cardiff and the Vale, and Cwm Taf, implementing the recommendation for dual expertise in diabetes and eating disorders. However, this is one post within one eating disorders service, covering adults presenting with T1DE within certain health boards. If this proves successful, there is a strong argument that experienced specialist diabetes nurses should be appointed within all eating disorders services, including Paediatric care, in order to meet the recommendation for a ‘national multidisciplinary subspecialist team within the national eating disorder service’.

At present, no other health board in Wales has T1DE specific services.

There is a complete lack of inpatient eating disorder units in Wales and according to the review there are significant differences in eating disorders services across Wales, with each health board working independently to provide adequate services, rather than an All Wales approach. If patients require admission for re-feeding, for example in the case of Anorexia Nervosa, they are admitted onto general medical wards, paediatric or adult. In some circumstances, children may be admitted to the North Wales Adolescent Service (NWAS) in Abergele or Litchard House Adolescent Unit in Bridgend. These units are generic CAMHS inpatient units, however when the review was undertaken a significant proportion of their inpatients were reported to have eating disorders.

Eating Disorder services for adults is based on the 2009 Framework with a 4-tiered approach, with patients being referred to a specific Tier depending on the severity of the Eating Disorder and the treatment and support required. Adult patients with T1DE within Cardiff and Vale, and Cwm Taf health boards are referred to SHED and due to their escalated risk of mortality come under Tier 3. For those patients requiring intensive inpatient specialist eating disorders care, including patients with T1DE, they need to travel to England or Scotland to receive this, isolating them from their family and friends who will be integral to their recovery as well as exerting huge financial implications. This does not take into account the emotional implications for the family and the increased risk of chronic ill health, divorce, PTSD and depression.

Difficulties arise when patients are presenting with T1DE behaviours but do not meet, or only meet 1 or 2 of, the MEED criteria and therefore are not supported by eating disorder teams. The behaviours still need to be addressed, especially where insulin restriction/omission is present, and a joint approach with diabetes and mental health teams still needs to be implemented. Knowledge and expertise of T1DE is imperative for patients experiencing behaviours of T1DE to be properly supported. If Eating Disorder services across Wales, and across Paediatric and Adult services, had a designated diabetes specialist nurse working in their teams this would bridge the gap providing the appropriate support, knowledge, and treatment the patients require to address their behaviours.

When it comes to admitting a patient with T1DE, whether paediatric or adult, collaborative working between the medical team, diabetes team and eating disorders team is imperative for stabilisation of blood glucose levels through gradual re-introduction of insulin and carbohydrate, alongside psychological treatment for the eating disorder (NICE 2017, RCPSYCH 2022). Healthcare professionals in these areas need to have a clear understanding that they are experiencing a significant clinical eating disorder, irrespective of their weight or BMI, and that appropriate treatment and support is imperative if they are to survive and recover. There needs to be fully trained and supportive staff available to support the patient and their families, with a knowledge of both Type 1 Diabetes and Eating Disorders due to the poor treatment outcomes and increased risk of morbidity and mortality. Designated diabetes specialist nurse across all eating disorder services, as there is within the SHED team, would fill this gap of knowledge and lack of expertise. Investment in Type 1 Diabetes and Eating Disorders is therefore required to reduce the acute and chronic complications associated with this dual-disorder.

References

Araia E, King RM, Pouwer F, Speight J, Hendrieckx C. Psychological correlates of disordered eating in youth with type 1 diabetes: Results from diabetes MILES Youth—Australia. Pediatric diabetes. 2020 Jun;21(4):664-72.

Goebel-Fabbri AE, Fikkan J, Franko DL, Pearson K, Anderson BJ, Weinger K (2008) Insulin restriction and associated morbidity and mortality in women with type 1 diabetes. Diabetes Care, 31(3): 415-9

Jones JM et al. (2000) Eating Disorders in Adolescent Females with and without Type 1 Diabetes: challenges in diagnosis and treatment: cross sectional study. BMJ 2000. 320 (7249)1563-6

National Institute for Clinical Excellence (NICE) 2017 Eating Disorders: recognition and treatment (NG69)

Nip AS, Reboussin BA, Dabelea D, Bellatorre A, Mayer-Davis EJ, Kahkoska AR, Lawrence JM, Peterson CM, Dolan L, Pihoker C. Disordered eating behaviors in youth and young adults with type 1 or type 2 diabetes receiving insulin therapy: The SEARCH for Diabetes in Youth Study. Diabetes care. 2019 May 1;42(5):859-66.

Pinhas-Hamiel Q et al. (2015) Eating Disorders in Adolescents with Type 1 Diabetes. Challenges in Diagnosis and Treatment. World J Diabetes 6 (3) 517-26

Reveler RC, Fairburn CG (1992) The treatment of bulimia nervosa in patients with diabetes mellitus. International Journal of Eating Disorders, 11(1): 45-53. 4.

Royal College of Psychiatrists (2022) Guidance on Recognising and Managing Medical Emergencies in Eating Disorders. Annexe 3 Type 1 Diabetes and Eating Disorders

Staite E et al (2018) ‘Diabulimia’ through the lens of social media: a qualitative review and analysis of online blogs by people with Type 1 Diabetes mellitus and eating disorders. Diabetes Medicine 35 (10) 1329-36

Staite E, Zaremba N, Macdonald P, Allan J, Treasure J, Ismail K, et al (2018) ‘Diabulima’ through the lens of social media: a qualitative review and analysis of online blogs by people with Type 1 diabetes mellitus and eating disorders. Diabet Med, 35(10): 1329-36.

Welsh Assembly Government (2018) Welsh Government Eating Disorder Service Review 2018

Young V, Eiser C, Johnson B, Brierley S, Epton T, Elliott J, Heller S. Eating problems in adolescents with Type 1 diabetes: a systematic review with meta‐analysis. Diabetic medicine. 2013 Feb;30(2):189-98

Trosolwg o’r Gwasanaethau Anhwylderau Bwyta Cyfredol yng Nghymru ar gyfer cleifion â Diabetes Math 1 a Bwyta Anhwylus(T1DE)

Rachael Humphreys, Arweinydd Nyrsio Cymru Gyfan ar gyfer Diabetes Math 1 ac Anhwylderau Bwyta (T1DE)

Diabetes Math 1

Mae diabetes Math 1 yn gyflwr awto-imiwn lle mae’r hormon inswlin yn cael ei ddinistrio, sy’n arwain at ddiffyg inswlin llwyr. Mae inswlin yn hanfodol ar gyfer bywyd, gan sefydlogi lefelau glwcos yn y gwaed a chaniatáu i’r corff ddefnyddio’r glwcos yn effeithiol ar gyfer ynni; heb inswlin, ni all pobl oroesi. Mae rheoli Diabetes Math 1 yn gymhleth. Mae pobl sy’n byw gyda Diabetes Math 1 yn dilyn cyfundrefnau dwys lle mae inswlin yn cael ei ddisodli trwy sawl pigiad dyddiol neu therapi pwmp inswlin parhaus i sefydlogi lefelau glwcos yn y gwaed. O’r diagnosis ymlaen, disgwylir i bobl sy’n byw gyda Diabetes Math 1, neu eu rhieni/gofalwyr yn achos cleifion pediatrig, gynnal lefelau glwcos sefydlog yn y gwaed trwy baru bwyd sy’n cynnwys carbohydrad â’r swm cywir o inswlin; cyfrif carbohydradau yw’r enw ar hyn. O’r diagnosis, mae’n rhaid i bobl â Diabetes Math 1 ystyried faint o garbohydrad sydd yn eu bwyd, beth yw lefel glwcos eu gwaed, a ydyn nhw ar fin ymgymryd ag unrhyw weithgarwch, neu a ydyn nhw’n sâl, er mwyn gwneud penderfyniadau synhwyrol ynghylch faint o inswlin sydd ei angen arnyn nhw. Os na fyddant yn cyfrifo hyn yn gywir, gall lefelau glwcos eu gwaed amrywio, ac mae hyn yn ei dro yn gofyn am reolaeth bellach. Mae eu hymwybyddiaeth o fwyd, yn enwedig carbohydrad, sy’n brif ffynhonnell glwcos iddynt, yn cael ei chynyddu, a chânt eu cyflwyno i’r cysyniad o bwyso bwyd, niferoedd, cywirdeb a pherffeithrwydd o ran cynnal lefelau glwcos o fewn yr ystod, cyfrif carbohydrad yn gywir, a chyrraedd HbA1c ‘targed’.

Oherwydd y cymhlethdodau sy’n ymwneud â rheoli Diabetes Math 1, mae pobl sy’n byw â’r cyflwr mewn mwy o berygl o bryder ac iselder oherwydd eu bod yn colli eu hiechyd, ac yn methu â rheoli hynny (Nip et al.2019, Araia et al. 2020) Mae hyn yn ei dro yn cynyddu eu risg o ddatblygu Ymddygiad Bwyta Anhwylus Math 1 (T1DE), sef amrywiaeth o ymddygiadau sy’n ceisio rheoli pwysau (RCPSYCH 2022). Adroddwyd bod anhwylderau bwyta ddwywaith yn fwy cyffredin mewn pobl â diabetes math 1 na’r rhai heb y cyflwr, ac maent yn bresennol mewn hyd at 30% o bobl â diabetes math 1 (Jones et al. 2000), ac mae defnyddio cyfyngu inswlin fel ymddygiad ymwacáu yn arwain at gyfradd uwch o gymhlethdodau diabetes acíwt a chronig (Pinhal-Hamiel 2015, Staite et al. 2018). Ymhlith plant a phobl ifanc â Diabetes Math 1, mae gan 7% anhwylder bwyta sy’n arwyddocaol yn glinigol (Young et al. 2013). O fewn gwasanaethau diabetes, credir bod llawer mwy o bobl wedi profi T1DE, neu’n parhau i brofi T1DE, heb gydnabyddiaeth na diagnosis ffurfiol.

Yn ôl Coleg Brenhinol y Seiciatryddion (RCPSYCH 2022), gall ymddygiadau mewn pobl â Diabetes Math 1 i reoli pwysau gynnwys:

Hepgor inswlin neu gyfyngu ar inswlin
Cyfyngu ar fwyd
Gwneud gormod o ymarfer corff
Chwydu Hunanachosedig
Camddefnyddio carthyddion neu ddiwretigion
Gall meddyginiaethau a ddefnyddir ar gyfer rheoli thyroid/diabetes gael eu camddefnyddio i leihau pwysau’r corff hefyd
Chwistrellu gormod o inswlin i guddio gor-fwyta mewn pyliau neu ofn cymhlethdodau acíwt sy’n gysylltiedig ag hepgor inswlin

Mae hepgor inswlin neu gyfyngu ar inswlin at ddibenion rheoli pwysau yn rhoi cleifion mewn perygl uchel o ddatblygu Cetoasidosis Diabetig, a all fod yn fygythiad i fywyd, ac sy’n gysylltiedig â chynnydd tair gwaith mewn marwolaethau ac ansawdd bywyd is (Staite et al. 2018, Goebbel-Fabri ac eraill. 2008, Reveler a Fairburn 1992). Mae cymhlethdodau hirdymor hepgor neu gyfyngu inswlin yn cynnwys retinopathi, neffropathi, a niwropathi, a all arwain at drychiadau i aelodau, a chlefyd y galon. Mae chwistrellu gormod o inswlin yn rhoi cleifion mewn perygl uchel o gael hypoglycemia difrifol, a all arwain at anymwybyddiaeth, a gall fod yn fygythiad i fywyd. Lle mai hepgor neu gyfyngu inswlin yw’r ymddygiad mwyaf amlwg, mae ailgyflwyno inswlin a charbohydrad yn gofyn am ddull gofalus a graddol i leihau’r risg o ostwng lefelau glwcos yn rhy gyflym; gall hyn yn ei dro gynyddu’r risg o retinopathi a niwropathi (Sefydliad Cenedlaethol dros Ragoriaeth Glinigol 2017, RCPSYCH 2022).

Mae gwneud diagnosis o T1DE yn gymhleth, ac mae RCPSYCH wedi cynnig meini prawf diagnostig i gynorthwyo gweithwyr gofal iechyd proffesiynol i nodi a yw’r patrymau ymddygiad yn gysylltiedig â T1DE, neu a ellir camgymryd ffactorau eraill sy’n gysylltiedig â diabetes am T1DE, er enghraifft anhawster derbyn y diagnosis, gofid diabetes, ac ymddieithrio o’u gwasanaeth diabetes. Mae’n bwysig y gall gweithwyr gofal iechyd proffesiynol wahaniaethu a nodi a yw pryderon ynghylch corff, pwysau a siâp unigolyn yn ffactorau amlwg a chael eu harwain gan y meini prawf a gynigir gan RCPSYCH i sicrhau bod cleifion yn cael triniaeth a chymorth priodol.

Pobl â Diabetes Math 1 sy’n bodloni’r tri maen prawf ar gyfer T1DE, sef:

Ofn gwirioneddol y byddant yn ennill pwysau, neu bryderon delwedd y corff, neu ofn y bydd inswlin yn peri iddynt ennill pwysau
Cyfyngiad uniongyrchol neu anuniongyrchol* amhriodol rheolaidd ar inswlin (a/neu ymddygiad cydadferol arall**) i atal ennill pwysau
Yn cyflwyno gyda rhywfaint o gyfyngiad inswlin, ymddygiadau bwyta neu gydadferol, sy’n achosi o leiaf un o’r canlynol:
Niwed i iechyd
Gofid diabetes arwyddocaol yn glinigol
Nam ar swyddogaeth ddyddiol

*Mae cyfyngiad anuniongyrchol ar inswlin yn cyfeirio at ostyngiad yn yr angen am inswlin / y defnydd ohono oherwydd cyfyngiad sylweddol ar garbohydradau

**Sef cyfyngu ar ddeiet, chwydu hunanachosedig, defnyddio carthyddion, gwneud gormod o ymarfer corff, gor-ddefnyddio hormonau thyroid, gor-ddefnyddio meddyginiaeth diabetes y credir eu bod yn helpu i osgoi ennill pwysau neu’n hyrwyddo colli pwysau**

Lle mae pryder bod T1DE gyda chlaf, mae angen cysylltiadau â thimau anhwylderau bwyta, iechyd meddwl a diabetes – oherwydd cymhlethdod T1DE, mae angen i arbenigwyr diabetes ac anhwylderau bwyta gydweithio â’r claf i sicrhau bod triniaeth briodol yn cael ei darparu. Mae RCPSYCH a NICE yn argymell model gofal a rennir. Lle mae angen derbyn claf i’r ysbyty, mae cydweithio rhwng y tîm diabetes, timau meddygol, gwasanaethau iechyd meddwl, gwasanaeth anhwylderau bwyta, a seiciatreg yn hanfodol. Mae angen dull cydweithredol o ailgyflwyno inswlin a charbohydradau, lle mae inswlin a/neu garbohydrad wedi’i hepgor neu ei gyfyngu, gyda’r nod o atal ennill pwysau’n gyflym sy’n gysylltiedig ag ailgyflwyno inswlin, yn ogystal â lleihau’r risg o gael retinopathi a niwropathi (NICE 2017, RCPSYCH 2022). Mae monitro cleifion â Diabetes Math 1 yn agos am hypoglycemia, hyperglycemia, Cetoasidosis Diabetig, gwenwyndra glwcos, ac edema yn hanfodol wrth reoli eu lefel o risg, gan ddibynnu ar eu hymddygiadau anhwylder bwyta, e.e. cyfyngu ar inswlin/carbohydradau, bwlimia nerfosa, anhwylder gorfwyta mewn pyliau (NICE 2017, RCPSYCH 2022)

Rhaid nodi yma y bydd gan y rhan fwyaf o gleifion â T1DE bwysau arferol a BMI yr ystyrir ei fod o fewn yr ystod iach, ac ni ellir eu defnyddio fel modd adnabod T1DE wrth wneud diagnosis. Gall hyn fod yn arbennig o anodd wrth geisio atgyfeirio cleifion at wasanaethau anhwylderau bwyta ac mae angen i’r risg ganolbwyntio ar y meini prawf a restrir uchod, yn hytrach na phwysau isel/BMI isel.

Gwasanaethau Anhwylderau Bwyta Cyfredol yng Nghymru

Yn 2019, ysgrifennodd y Gweinidog Iechyd a Gwasanaethau Cymdeithasol ar y pryd, Vaughan Gething AC/AM, at Brif Weithredwyr Byrddau Iechyd yn dilyn adolygiad annibynnol i Anhwylderau Bwyta yng Nghymru, gydag argymhellion i wella gwasanaethau a chanlyniadau i gleifion. Roedd yr adolygiad, a gyhoeddwyd ym mis Tachwedd 2018, yn cydnabod bod angen newid, yn enwedig o ran atal ac adnabod a thrin cleifion yn gynnar cyn iddynt fynd yn sâl iawn. Nododd yr adroddiad fod gwasanaethau anhwylderau bwyta yng Nghymru yn brin o adnoddau sylweddol, a bod angen buddsoddiad sylweddol i wella profiad a chanlyniadau cleifion.

Roedd yr adroddiad yn myfyrio ar y ‘risgiau cynyddol iawn o anhwylderau deuol, fel Diabetes Math 1 ac anhwylder bwyta … ac mae gwasanaethau fel diabetes pediatrig bellach yn dechrau cydnabod bod angen dull integredig rhwng y gwasanaethau hyn’ (LlCC, 2018, t7). Rhestrir yr argymhellion o’r adolygiad hwn isod:

Rhaid i dimau anhwylderau bwyta a diabetes Cymru ar gyfer plant a phobl ifanc ac oedolion ddatblygu protocolau cenedlaethol i gydweithio dros gleifion sydd ag anhwylderau bwyta a diabetes. Dylai fod arweinwyr cenedlaethol mewn anhwylderau bwyta a gwasanaethau diabetes a all gydweithio i ddatblygu hyfforddiant ac ymwybyddiaeth ymhlith staff yn y ddwy system, ac i weithio’n benodol i nodi a rheoli cleifion â diabetes sy’n bwyta’n anhwylus neu sydd ag arwyddion cynnar o anhwylderau bwyta. O ystyried yr heriau mawr sy’n benodol i ddiabetes a’r risgiau meddygol uchel sy’n gysylltiedig â rheoli cleifion sydd â diabetes ac anhwylderau bwyta, rydym yn argymell tîm is-arbenigol amlddisgyblaethol cenedlaethol o fewn y gwasanaeth anhwylderau bwyta cenedlaethol sydd ag arbenigedd deuol ym maes diabetes ac anhwylderau bwyta.

Dylai Llywodraeth Cymru sicrhau y dylid glynu wrth ganllawiau NICE ar gyfer diabetes a bod gan dimau diabetes fewnbwn seicolegwyr ar gyfer eu cleifion sy’n fedrus wrth nodi a rheoli bwyta anhwylus.

Ers yr adroddiad hwn, mae Grŵp Gweithredu Diabetes Cymru Gyfan wedi’i sefydlu, gydag Arweinydd Prosiect Cymru Gyfan ar gyfer T1DE (3.5 awr/wythnos) yn y swydd. Sefydlwyd grŵp llywio fforwm clinigol Cymru gyfan gyda chynrychiolaeth o bob bwrdd iechyd ym meysydd gwasanaethau diabetes pediatrig ac oedolion, gwasanaethau iechyd meddwl, a gwasanaethau anhwylderau bwyta. Mae gan bob bwrdd iechyd arweinwyr dynodedig o fewn eu gwasanaeth i weithredu newidiadau o fewn eu gwasanaeth, ac mae grwpiau ymgynghori rhwng gwasanaethau diabetes ac anhwylderau bwyta ar draws y byrddau iechyd bellach wedi’u sefydlu. Mae lle i wella o hyd – mae meithrin hyder y tîm wrth adnabod T1DE yn flaenoriaeth, yn ogystal ag offer sgrinio cytûn ac atgyfeiriadau at wasanaethau anhwylderau bwyta os caiff claf sy’n bodloni’r meini prawf ar gyfer T1DE ei adnabod. Gall fod gormod o ffocws o hyd ar bwysau a BMI, ac felly gwelir anghytgord mewn cleifion â T1DE sy’n cyrraedd y trothwy ar gyfer gwasanaethau anhwylderau bwyta. Mae cydnabod meini prawf arfaethedig RCPSYCH yn hanfodol wrth gydnabod y risg gynyddol y mae’r garfan cleifion hon yn ymgyflwyno â hi oherwydd hepgor inswlin, a’u risg sylweddol o niwed a marwolaeth yn ddi-oed.

Yn 2022, cyflogwyd y nyrs arbenigol diabetes oedolion llawn amser gyntaf gan SHED, sef y Gwasanaeth ar gyfer Anhwylderau Bwyta Risg Uchel sy’n cwmpasu Caerdydd a’r Fro, a Chwm Taf, gan weithredu’r argymhelliad ar gyfer arbenigedd deuol mewn diabetes ac anhwylderau bwyta. Fodd bynnag, un swydd yw hon o fewn un gwasanaeth anhwylderau bwyta, sy’n cwmpasu oedolion sy’n cyflwyno â T1DE o fewn rhai byrddau iechyd. Os bydd hyn yn llwyddiannus, mae dadl gref y dylid penodi nyrsys diabetes arbenigol profiadol o fewn pob gwasanaeth anhwylderau bwyta, gan gynnwys gofal pediatrig, er mwyn bodloni’r argymhelliad ar gyfer ‘tîm is-arbenigol amlddisgyblaethol cenedlaethol o fewn y gwasanaeth anhwylderau bwyta cenedlaethol’.

Ar hyn o bryd, nid oes gan unrhyw fwrdd iechyd arall yng Nghymru wasanaethau penodol ar gyfer T1DE.

Mae diffyg llwyr o unedau anhwylderau bwyta cleifion mewnol yng Nghymru, ac yn ôl yr adolygiad, mae gwahaniaethau sylweddol mewn gwasanaethau anhwylderau bwyta ledled Cymru, gyda phob bwrdd iechyd yn gweithio’n annibynnol i ddarparu gwasanaethau digonol, yn hytrach na dull Cymru Gyfan. Os oes angen derbyn cleifion i’r ysbyty i fwydo eto, er enghraifft yn achos Anorecsia Nerfosa, cânt eu derbyn i wardiau meddygol cyffredinol, pediatrig neu oedolion. O dan rai amgylchiadau, gellir derbyn plant i Wasanaeth Pobl Ifanc Gogledd Cymru (NWAS) yn Abergele neu Uned Pobl Ifanc Tŷ Litchard ym Mhen-y-bont ar Ogwr. Unedau cleifion mewnol CAMHS generig yw’r unedau hyn, fodd bynnag, pan gynhaliwyd yr adolygiad, adroddwyd bod gan gyfran sylweddol o’u cleifion mewnol anhwylderau bwyta.

Mae gwasanaethau Anhwylderau Bwyta i oedolion yn seiliedig ar Fframwaith 2009, gyda dull 4 haen; mae chleifion yn cael eu cyfeirio at Haen benodol gan ddibynnu ar ddifrifoldeb yr Anhwylder Bwyta a’r driniaeth a’r cymorth sydd eu hangen. Mae cleifion sy’n oedolion â T1DE o fewn byrddau iechyd Caerdydd a’r Fro, a Chwm Taf yn cael eu hatgyfeirio at SHED ac oherwydd eu risg uwch o farwolaeth, maent yn dod o dan Haen 3. Mae ange i’r cleifion hynny sydd angen gofal anhwylderau bwyta arbenigol dwys fel cleifion mewnol, gan gynnwys cleifion â T1DE deithio i Loegr neu’r Alban i gael hyn; mae hyn yn eu hynysu oddi wrth eu teulu a’u ffrindiau a fydd yn hanfodol i’w hadferiad, ac mae hefyd yn cael goblygiadau ariannol enfawr. Nid yw hyn yn ystyried y goblygiadau emosiynol i’r teulu a’r risg uwch o salwch cronig, ysgariad, PTSD ac iselder.

Mae anawsterau’n codi pan fydd cleifion yn ymgyflwyno gydag ymddygiadau T1DE ond nad ydynt yn bodloni meini prawf MEED, neu maent ond yn bodloni 1 neu 2 ohonynt, ac felly nid ydynt yn cael eu cefnogi gan dimau anhwylderau bwyta. Mae angen mynd i’r afael â’r ymddygiadau o hyd, yn enwedig lle gwelir cyfyngu ar inswlin / ei hepgor, ac mae angen gweithredu dull ar y cyd â thimau diabetes ac iechyd meddwl o hyd. Mae gwybodaeth ac arbenigedd am T1DE yn hanfodol er mwyn i gleifion sy’n profi ymddygiadau T1DE gael eu cefnogi’n iawn. Pe bai gan wasanaethau Anhwylderau Bwyta ledled Cymru, ac ar draws gwasanaethau Pediatrig ac Oedolion, nyrs arbenigol diabetes ddynodedig yn gweithio yn eu timau, byddai hyn yn pontio’r bwlch, gan ddarparu’r wybodaeth, y driniaeth a’r cymorth priodol sydd eu hangen ar gleifion i fynd i’r afael â’u hymddygiadau.

O ran derbyn claf â T1DE, boed yn glaf pediatrig neu’n glaf sy’n oedolyn, mae cydweithio rhwng y tîm meddygol, y tîm diabetes a’r tîm anhwylderau bwyta yn hanfodol ar gyfer sefydlogi lefelau glwcos yn y gwaed trwy ailgyflwyno inswlin a charbohydradau’n raddol, ochr yn ochr â thriniaeth seicolegol ar gyfer yr anhwylder bwyta (NICE 2017, RCPSYCH 2022). Mae angen i weithwyr gofal iechyd proffesiynol yn y meysydd hyn fod â dealltwriaeth glir bod y claf yn profi anhwylder bwyta clinigol sylweddol, waeth beth fo’i bwysau neu eu BMI, a bod triniaeth a chymorth priodol yn hanfodol os bydd am oroesi a gwella. Mae angen sicrhau bod staff cefnogol sydd wedi’u hyfforddi’n llawn ar gael i gefnogi’r cleifion a’u teuluoedd, sy’n meddu ar wybodaeth am Ddiabetes Math 1 ac Anhwylderau Bwyta oherwydd y canlyniadau triniaeth gwael a’r risg uwch o afiachedd a marwolaeth. Byddai nyrs arbenigol diabetes ddynodedig ar draws yr holl wasanaethau anhwylderau bwyta, fel sydd gan dîm SHED, yn llenwi’r bwlch hwn mewn gwybodaeth a diffyg arbenigedd. Felly mae angen buddsoddi mewn Diabetes Math 1 ac Anhwylderau Bwyta i leihau’r cymhlethdodau acíwt a chronig sy’n gysylltiedig â’r anhwylder deuol hwn.

Cyfeiriadau

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Jones JM et al. (2000) Eating Disorders in Adolescent Females with and without Type 1 Diabetes: challenges in diagnosis and treatment: cross sectional study. BMJ

Y Sefydliad Cenedlaethol dros Ragoriaeth mewn Iechyd a Gofal (NICE) 2017 Eating Disorders: recognition and treatment (NG69)

Pinhas-Hamiel Q et al. (2015) Eating Disorders in Adolescents with Type 1 Diabetes. Challenges in Diagnosis and Treatment. World J Diabetes 6 (3) 517-26

Reveler RC, Fairburn CG (1992) The treatment of bulimia nervosa in patients with diabetes mellitus. International Journal of Eating Disorders, 11(1): 45-53. 4

Coleg Brenhinol y Seiciatryddion (2022) Guidance on Recognising and Managing Medical Emergencies in Eating Disorders. Atodiad 3 Type 1 Diabetes and Eating Disorders

Llywodraeth Cynulliad Cymru (2018) Adolygiad Gwasanaeth Anhwylderau Bwyta Llywodraeth Cymru 2018