Co-Morbid Conditions: Diabetes and Eating Disorders Beverly Price, RD, MA, RYT

Pathogenesis

What comes first? Studies indicate that the diagnosis of diabetes usually precedes the onset of an eating disorder (Powers et al., 1983; Hilliard & Hilliard, 1984) and has also been confirmed by Ward, Troop, Cachio, Watkins, and Treasure (1995). The actual precipitant for eating disorders in patients with diabetes may be the typical weight gain that occurs following the initiation of insulin therapy. In predisposed adolescent females, this weight gain may trigger the onset of eating disorders, often with omission of insulin. The chronic dietary restraint and preoccupation with carbohydrate restriction may further foster the development of eating disorders.

Complications

Patients with diabetes who also have eating disorders are more likely to have both short-term and long-term complications of their diabetes than non-eating disordered diabetics. Insulin misuse and binge eating both contribute to poor diabetic control. The most common and best-known misuse of insulin is omission or reduction of the dose, causing glycosuria and weight loss. However, some patients who binge-eat may take large doses of insulin to compensate and may gain weight as a consequence. Anorexia nervosa in patients who have severely restricted their diets or who overexercise may fail to reduce their insulin doses appropriately and may become hypoglycemic.

HbA1c levels are higher in patients with diabetes that are also diagnosed with an eating disorder than in patients with diabetes who do not have eating disorders (Wing et al., 1986; Birk & Spencer, 1989; Steel, Young, Lloyd, & Clarke, 1987) and are more at risk for developing long-term complications. Rydall, Rodin, Olmsted, Devenyi, and Daneman (1994) found that 90% of young women who had a previously suspected eating disorder had early signs or either diabetic retinopathy or nephropathy, compared to 40% without a suspected eating disorder. Cantwell and Steel (1996) confirmed that diabetic complications are growth failure and pubertal delay (Rodin et al., 1985).

The short-term complications include unexpected episodes of diabetic ketoacidosis or severe hypoglycemia (Powers, Malone, & Duncan, 1983; Hilliard & Hilliard. 1984). Patients with anorexia nervosa may develop acute painful neuropathy at the peak or weight reduction (Steel et al., 1987).

Unexpected, unexplained episodes of ketoacidosis or hypoglycemia, particularly in an adolescent female, should alert the physician or diabetes educator to the possibility of an eating disorder. If blood sugar is easily normalized during a hospital admission, this is another warning sign. Weight loss or weight gain should be carefully monitored, and the patient should be evaluated for other signs and symptoms of an eating disorder. Other indications include poor adherence to general management of the diabetes, high HbA1c levels, or growth failure.

Patients with diabetes and a concurrent eating disorder may purge by vomiting, laxative abuse, or diuretic abuse (Fairburn, Peveler, Davies, Mann, & Mayou, 1991). Binge eating can be very dangerous, since diabetic control can be impaired with small quantities of high-carbohydrate foods.

Treatment

Patients with anorexia nervosa and diabetes almost always require hospitalization. Treatment should include weight restoration and normalization of eating, both individual and family therapy, and nutritional counseling. Initially, the nursing staff may need to inject each insulin dose. Careful supervision by nursing is required as some patients may be so determined to lose weight that they secretly dispose of insulin. If there are unexplained variations in blood sugar, or if an anorexic patient fails to gain weight despite appropriate caloric intake, it may be helpful to have members of the nursing staff not only administer the insulin but sign for its administration as they would for a narcotic. The patient may report false blood sugar levels unless monitored closely. As the patient improves and is able to cooperate with the treatment, very close monitoring of blood sugars is necessary, as insulin requirements may change dramatically when weight is gained or when binge eating is discontinued.

Nutritional consultation can be very challenging. Many patients with eating disorders are unnecessarily rigid in their food choices, whereas others discount the effect of binge eating if they believe that omitting insulin (or taking a higher dose) has compensated for possible weight gain (or effect on blood glucose). It may be more difficult for an overweight bulimic to lose weight and still follow a diabetic diet. Body fat content is most-likely higher in patients with diabetes than in age, weight-matched peers. This higher fat content may mean that with normal caloric intake, especially in a patient with a long-standing history of bulimia, weight gain will occur more readily. The patient may have to choose between a slightly lower caloric intake (which may increase hunger and thus vulnerability to binge eating) and a slightly higher weight (which may intensify body image dissatisfaction). It is a vicious circle.

Individual psychotherapy is often characterized by denial of both the eating disorder and the diabetes or of their meanings, in terms of both decreased longevity and need for alteration in lifestyle. Some patients may believe that if they become thin enough, they will not have diabetes. This flawed belief is given some credibility by the fact that insulin requirements do decrease with weight loss. The conflict between autonomy and dependence may be particularly difficult for diabetic adolescents. These young patients must assume responsibility for management of their illness early, yet they are dependent on treatment and care providers for their survival. Issues related to grief over loss of normal daily functioning are also important, particularly in patients who have difficulty expressing their emotions.

Family issues may be very important. Parents may feel guilty about their child’s illness (especially if one or both parents have a family history of diabetes) and may overindulge a clinically ill child or teenager. On the other hand, parents may distance themselves inappropriately from a diabetic adolescent, who may appear mature because of having to manage the diabetes. It may be difficult for a family to facilitate suitable independence in a youngster with an eating disorder who also has diabetes. Family conflicts may be shifted into conflicts over compliance with diabetic treatment.

Cognitive-behavioral techniques, typically in group settings, have been used for patients that have diabetes along with bulimia nervosa (Peveler & Fairburn, 1992) or anorexia nervosa (Peveler & Fairburn, 989). These techniques may be less effective in the diabetic population than in the general eating disorder population.

Prevention

The need for a flexible approach to treatment and for cooperative rather than compliant interaction with care providers are crucial to preventing eating disorders among newly diagnosed patients with diabetes (Lawson et al. 1994).

Beverly Price is a registered dietitian, exercise physiologist and registered yoga teacher who offers individual nutrition and yoga therapy in Bingham Farms and Royal Oak, Michigan. She also conducts yoga and eating disorder recovery programs along with continuing education for dietitians, diabetes educators and other healthcare professionals. For more information, log on to www.bevprice.com and www.gettingthatjumpstart.com

References

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Drash, A. (1987). Clinical care of the diabetic child. Chicago: Year Book Medical.
Garner, D.M., Olmsted, M.P., Bohr, Y., & Garfinkel, P.E. (1982) The Eating Attitudes Test: Psychometric features and clinical correlates. Psychological Medicine, 12, 871-878.
Hilliard, J.R., & Hilliard, P.J.A. (1984). Bulimia, anorexia nervosa and diabetes: Deadly combinations. Psychiatric Clinics of North America, 7, 367-379.
Hudson, J.I., Wentworth, S.M., Hudson, M.S., & Pope, H.G. (1985). Prevalence of anorexia nervosa and bulimia among young diabetic women. Journal of Clinical Psychiatry 46,88-89.
Peveler, R.C., & Fairburn, C.G. (1989). Anorexia nervosa in association with diabetes mellitus: A cognitive-behavioral approach to treatment. Behavior Research and Therapy, 27, 95-99.
Peveler, R.C., & Fairburn, C.G. (1992). The treatment of bulimia nervosa in patients with diabetes mellitus. International Journal of Eating Disorders, 11,45-53.
Powers, P.S., Malone, J.I., Coovert, D.L., & Schulman, R. G. (1990). Insulin=dependent diabetes mellitus and eating disorders: A prevalence study. Comprehensive Psychiarty, 31, 205-210.