By Gary Scheiner, MS, CDE
Living with diabetes is filled with challenges. One of those challenges involves paying very careful attention to food. Is this the right portion size? Does it have too many calories? Too much fat? The wrong kind of fat? How much carbohydrate does it contain? And when, exactly, should it be eaten?
This “preoccupation” with food, and doing things like labeling foods as “good and bad” or “allowed and forbidden” can create a very unhealthy relationship. It can even lead to something called an eating disorder. For teenaged girls and young women who are already at an increased risk for eating disorders, this can create a serious problem.
Women with Type 1 Diabetes at Increased Risk
Girls and young women with type 1 diabetes have more than twice the risk of developing an eating disorder compared to their peers without diabetes. It certainly does not help that intensive insulin treatment—multiple daily injections or use of an insulin pump—is often associated with weight gain. And many other behaviors that are part of managing diabetes (counting carbs, exercising, frequent blood sugar checks) may also contribute to the development of eating disorders in women with diabetes.
The two main eating disorders are anorexia nervosa and bulimia nervosa. People with anorexia view their body unrealistically and dramatically restrict their food intake to stay thin. Bulimia is a condition in which individuals repeatedly eat excessive amounts of food and then purge through vomiting or laxative use.
In a study of girls age 12 to 18 with type 1 diabetes, 45% admitted to binge eating, 8% to self-induced vomiting, and 2% to laxative abuse. Additionally, 14% admitted to deliberately not taking enough insulin as a means of controlling weight. A few years later, at age 19, more than half of these same girls suffered from binge eating, and more than a third were skipping insulin doses intentionally.
It does not take long for most people with type-1 diabetes to learn the relationship between their insulin doses and how much they weigh. It is estimated that 10% to 20% of teenage girls and 30% to 40% of young adult women with diabetes skip or alter their insulin doses to control their weight. This condition has been referred to as “diabulimia.” According to the Juvenile Diabetes Research Foundation (JDRF), diabulimia can have devastating and permanent effects on the body.
When a person with type-1 diabetes intentionally takes less insulin than what they need, blood sugar levels rise very high and a great deal of the sugar “spills” through the kidneys and into the urine. This results in rapid weight loss, similar to when a person with bulimia intentionally vomits after eating, hence the term “diabulimia.”
The short-term effects of very high blood sugar levels include dehydration, fatigue, extreme thirst and hunger, mood changes, poor healing, and impaired brain and muscle function. Over the course of several years, frequent and severe high blood sugar levels can cause blindness, kindey failure, nerve disorders and heart disease… sometimes at a very young age.
Without insulin altogether or with very small amounts, a person with type-1 diabetes can also develop a life-threatening condition called ketoacidosis. This is due to the buildup of acid from excessive fat breakdown. Symptoms include intense vomiting, deep/labored breathing, a “rotten fruit”-smelling breath, headache, muscle aches, and delirium.
Death is not uncommon in women with diabetes who have eating disorders. Women with type 1 diabetes who restrict their insulin doses have a three times higher rate of death than women who use appropriate insulin doses.
Treatment for an individual who severely restricts or skips insulin doses requires both an eating disorder specialist and a diabetes management team in order to be effective.
If you think that you or someone close to you has an eating disorder, talk to your doctor and diabetes educator. They can refer you to a mental health counselor who specializes in these types of situations. They are nonjudgmental and supportive. Remember, eating disorders and insulin restriction are very dangerous and difficult to deal with on your own. It is extremely important to seek help from an expert..
Food Is Not Toxic
Dr. Ann Goebel-Fabbri is a clinical psychologist at the Joslin Diabetes Center. Her research focuses on the link between eating disorders and diabetes. She believes that developing a healthy relationship with food and insulin at an early age can help prevent harmful behaviors such as insulin omission and restriction. “It is important for people to strive for a balanced, flexible approach to eating,” said Dr. Goebel-Fabbri “Kids and families need to lean that food isn’t toxic. It is possible to eat a tremendous variety at different times and still cover (with) insulin appropriately.”
The most common features of eating disorders in girls and young women with type 1 diabetes are:
dissatisfaction with body weight and shape
a desire to be thinner
dieting or manipulation of insulin doses to control weight
Recognizing the symptoms
changes in eating habits (eating more but still losing weight)
unexplained weight loss
unexplained high blood sugar
low energy levels
Editor’s note: Gary Scheiner is owner and clinical director of Integrated Diabetes Services (www.integrateddiabetes.com; 610-642-6055), a private practice specializing in advanced training and management of children and adults on intensive insulin therapy. His team of CDEs (all of whom have Type-1 diabetes) provides consultations worldwide via phone and the internet. Gary is author of several books including “Think Like A Pancreas” and was named 2014 Diabetes Educator of the Year by the American Association of Diabetes Educators. Feel free to submit questions and comments to email@example.com
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