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 multidisciplinary 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, selfempowerment, 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?
www.centerforhopeofthesierras.com
877.828.4949