Diabetes and Eating Disorders Ami Marsh, MS, MFT, LCADC

Diabetes and Eating Disorders “Having diabetes is the easiest way to have an eating disorder. I can go out to eat with my friends, eat anything I want, and purge during the meal without anyone knowing I am doing it.”

The Basics What is diabetes? Association between diabetes and eating disorders Treatment Other considerations

What is diabetes? Autoimmune disorder where insulin producing cells in the pancreas are destroyed. Insulin is the hormone that allows glucose to enter the cells, causing absorption of glucose into the body… which equals calorie absorption Two types of Diabetes -Type 1, Insulin Dependent -Type 2, Insulin Resistant

Diabulimia Not recognized in DSM-5 as a diagnosis. Diabulimia describes an eating disorder behavior associated primarily with Type 1 diabetes. Insulin dependent diabetics deliberately skip or reduce insulin dose for the purpose of losing weight or preventing weight gain. Extremely dangerous combination of eating disorder and diabetes mismanagement.

Diabulimia Insulin is the hormone that allows glucose to enter the cells, causing absorption of glucose into the body… which equals calorie absorption If one restricts glucose, it is eventually lost from the body in the urine – it is not absorbed, and neither are the calories from the glucose Some patients with diabetes call insulin “The Fat Hormone”. To them, insulin equals weight gain. Physical consequences: nerve damage, blindness, kidney failure, death

Diabulimia Other eating disorder behaviors are often present (restriction, bingeing, purging, over-exercising, judging self-worth by weight/body size, etc.). In some cases, these other symptoms may be subclinical. Diabulimic patients suffer the consequences of not taking care of a potentially life-threatening medical condition in addition to the risks associated with traditional eating disorders.

Development of Eating Disorders in Patients with Diabetes Patients may already have an eating disorder or disordered eating prior to diabetes diagnosis. Patients may also develop an eating disorder after diabetes diagnosis. –Diabetes may trigger an eating disorder in someone who is already susceptible.

Potential Warning Signs for Traditional Eating Disorders Weight loss (often despite increased or no change in food intake). Weight fluctuations. Hunger denial, secretive eating, or bingeing. Restricting or eliminating certain foods or food groups (“safe” and “forbidden” food lists). Inappropriate use of diet pills, diuretics, laxatives, enemas, ipecac, caffeine, hot or cold beverages, sugar-free gum, etc.

Warning Signs for Traditional Eating Disorders Fatigue, weakness, lethargy. Excessive exercise. Preoccupation/obsession with weight, body-image and/or food intake. Being overly critical of appearance. Amenorrhea –Removed from the DSM-5 but still important if present. Anxiety/depression/extreme mood changes. Severe self-criticism.

Warning Signs for Diabetes Related Eating Disorders All of the above, plus: Poor metabolic control (hyperglycemia and/or elevated HbA1c) despite reported compliance. Weight loss or weight maintenance despite unchanged or increased food intake. Recurrent DKA. Classic symptoms of unmanaged diabetes: excessive urination, excessive thirst, excessive hunger.

Eating Disorders and Diabetes Women with Type I DM are 2.5 times more likely to develop an eating disorder than women without diabetes. –Up to 40% of women with DM-T1 report engaging in eating disordered behaviors. –Up to 90% of teens living with diabetes report having modified insulin doses to lose weight. Among those with Type 1 DM, bulimia is the most common eating disorder reported. Binge Eating Disorder is more commonly reported among women with Type 2 DM.

Why might diabetic patients be at increased risk for developing eating disorders? Onset of diabetes is often associated with weight loss that diabetic does not want to give up. Insulin treatment often leads to increased hunger and weight gain, increasing likelihood of poor body image. Routine focus on weight at every doctor visit. Restrictive element of diabetic diet. Classification of foods as “allowed,” “forbidden,” “good” or bad”. Shame about food choices.

Why are diabetic patients at increased risk for eating disorders? Contraindication of high carbohydrate foods when blood glucose levels are elevated. Focus on numbers. Necessity of reading food labels. Need for ongoing close monitoring of diet, exercise, blood glucose levels and insulin dosages leads to obsessive thinking and unhealthy preoccupation with food and weight. Fear of bad experiences going low – eat to prevent or correct, then feel guilt about eating and fear that eating will lead to weight gain.

Why are diabetic patients at increased risk for eating disorders? Role of parents or others (“diabetes police”) in managing diabetes (control). Misconceptions/judgments of others: “You can’t eat that, you’re diabetic!” (lack of understanding/education). Need for control (controlling food and/or weight when one can’t control emotions or external situations). Use as a coping mechanism (emotional disassociation). Focus on exercise.

Why are diabetic patients at increased risk for eating disorders? Psychological issues associated with diagnosis and management of long-term illness (anger at diabetes). Diabetes diagnosis can contribute to triggering factors that often lead to eating disorders: low self-esteem, depression, anxiety and loneliness.

Increased Risks for Diabetic Patients with Eating Disorders If manipulating insulin: –Hyperglycemia –DKA –Elevated HbA1c levels –Earlier onset of degenerative complications of diabetes: Retinopathy (blindness) Kidney disease Heart disease Nerve damage Circulation problems –Higher early mortality rate than in diabetics without eating disorders

Increased Risks for Diabetic Patients with Eating Disorders If bingeing and/or purging: –Episodes of both hyperglycemia and hypoglycemia. Difficult to gauge appropriate insulin dose following a binge and/or purge episode. –Earlier onset of degenerative complications of diabetes. –All complications (physiological and psychological) associated with bulimia.

Treatment: Evidence based research suggests multi- disciplinary approach to be most effective form of treatment –At minimum, this is primary care provider, endocrinologist, dietitian and therapist all working together to provide integrative, full-circle care. –At higher levels of care, team also includes nursing, psychiatrist, direct line staff, continuing care.

Treatment Methods: Behavior Management Individual, family, and group therapy sessions –Body image, body appreciation, CBT, DBT, process group, emotion acceptance, anxiety management, yoga, meditation, equine therapy, reiki, massage, self- empowerment, recovery maintenance, creative expressions, relapse prevention, problem solving, goal development, lunch out Psychotropic medication aindicated –Antidepressant, mood stabilizer, anxiolytic, sleep aid, etc.

Treatment Methods: Medical Management 24 hour nursing Nursing support before, during and after meals and snacks to monitor blood glucose and determine insulin dose Daily monitoring of blood glucose logs Weekly meetings with endocrinologist Weekly meetings with primary care doctor Weekly meetings with diabetes educator Weekly or bi-weekly labs

Treatment Methods: Psychological Complexities Challenging core beliefs, “Something is wrong with me.” Increase sense of “self-as-context”- acceptance of diabetes Change the conditioned response – link dosing to feeling better Addressing the system– diabulimia education, patterns of interactions Body image and shame– dealing with an insulin pump or injections

Intuitive Eating & Diabetes Eat when hungry and stop when full. There are no good or bad foods. We teach our clients to dose for what they want to eat. Patients participate in carb counting from the first day of treatment -Key piece of diabetes education -Must be carefully navigated to avoid triggering the ED Patients are allowed to read labels for carb counting when appropriate. More to come on this next month!

Education for Recovery Education –Emphasis on intuitive food choices –Teaching carbohydrate counting –Modern education=less emphasis on restrictive diabetic diet –Life is centered around diabetes care: a lifestyle choice to care for your diabetes –Incorporating mindful exercise

It takes a village… Endocrinologist RD experienced in diabetes and eating disorders Therapists experienced in chronic disease and eating disorders 24-hour nursing care Resident Advisors Diabetes Group- talk about current issues, questions related to diabetes

Case Study Jane, 26 year old female. Jill, 45 year old female.

Conclusions Due to high comorbidity rate, assessment for eating disorders among those with T1-DM is crucial. Eating disorders are often tightly woven around diabetes issues…hunger cues, eating disorder urges, weight gain, depression and psych issues. Integrated care provided by a communicative treatment team is critical. Blood sugar stability is crucial to the patient’s recovery from psychological aspect of their eating disorder.

Questions?