Childhood Diabetes and Eating Disorders

Contributed Article by Sharon McConville MB BCh BAO

There are two types of diabetes.  Type 1 occurs when the pancreas fails to produce enough of a hormone called insulin, which regulates blood glucose.  It typically begins in childhood or adolescence and causes thirst, urinary frequency and weight loss.  Type 2 diabetes occurs when the body becomes resistant to insulin, and is associated with excess weight.  It usually arises in older adults but is increasingly being observed in overweight children.

There is an obvious link, then, between eating disorders such as compulsive eating and the development of Type 2 diabetes.  This article sets out to explore the link between Type 1 diabetes and the development of eating disorders in children and young people.

Why do people with diabetes get eating disorders?

It has been established that eating disorders including anorexia, bulimia and EDNOS (eating disorder not otherwise specified) arise twice as often in adolescent females with diabetes as in the normal adolescent population1.  There are a number of probable reasons for this phenomenon.  First of all, when a child or adolescent is diagnosed with diabetes, they have usually lost a significant amount of weight.  This is because, in uncontrolled diabetes, glucose from the blood leaves the body via the urine.  When treatment with insulin commences, there is normally weight gain.  If a young person is vulnerable to an eating disorder, they may find this body change difficult to deal with and may develop unhealthy strategies to lose weight.

Secondly, there is a unique method of controlling weight available to the diabetic young person.  By “under-dosing” with insulin, or failing to take insulin at all, a state of high blood glucose – equivalent to having uncontrolled diabetes – is induced, leading to weight loss.  Within the context of an eating disorder, this can be considered to be a form of “purging”.  Thirdly, young people with diabetes are obliged to engage with a self-care strategy which includes a restrictive meal plan.  Those with a predisposition to become obsessive about counting carbs, for example, may be at greater risk of developing an eating disorder as a diabetic than if they had never had to think about their diet.  Furthermore, many diabetic clinics counsel strongly against weight gain – advice which may be taken to the extreme by some vulnerable teenagers.  Finally, the effects of being diagnosed with a chronic illness on a young person cannot be underestimated: it may be enough to push those already predisposed to developing any mental illness over the clinical threshold.

How do eating disorders present in young people with diabetes?

Eating disorders may present acutely or more chronically in young people with diabetes.  For example, one teenager may have frequent Emergency Room admissions with diabetic keto-acidosis, a complication of high blood glucose, whilst another may present in the diabetic clinic with growth failure or weight loss and an elevated HbA1C (a measure of longer-term blood glucose levels).  Just as in any person with an eating disorder, routine serum electrolyte levels may be abnormal due to vomiting or diuretic abuse, or direct questioning may unveil over-valued ideas about body shape and size.  Most young people with diabetes develop a form of bulimia, sometimes called “diabulimia”, binge-eating disorder or EDNOS, with anorexia per se being less common.

What are the complications of eating disorders in young people with diabetes?

Adolescents with eating disorders are at greater risk of suffering complications of diabetes including diabetic keto-acidosis from under-dosing with insulin and hypoglycaemia from food restriction after taking insulin.  Both of these complications can be fatal or lead to organ failure.  Diabetes also predisposes to disease of the small blood vessels in the eyes, kidneys and nervous system due to high blood glucose levels.  The disease of small blood vessels in the eye, known as “retinopathy”, is significantly more common in young people with eating disorders, whose blood glucose levels are higher over time.  In general, medical complications of eating disorders – such as heart problems – occur more rapidly in young people with diabetes2.

What causes some diabetics to get eating disorders whilst others do not?

Just as there is no one factor which causes a non-diabetic person to develop an eating disorder, there are biological, psychological, social and spiritual factors at play when a young diabetic person develops one; however, the evidence suggests that there are some specific issues to consider when looking for the roots of eating disorders in diabetics.  For some young people with diabetes, problems within the family contribute to poor treatment compliance, leading to elevated HbA1C levels, which reflects prolonged periods of elevated blood glucose.  Similarly, research suggests that relational difficulties within families can be linked to the development of eating disorders in the general, non-diabetic population1.

Now studies are also beginning to show that eating disturbances in girls with diabetes may be associated with interpersonal problems within the family structure.  For example, a young person with diabetes who feels helpless within her family may try to boost her self-esteem through losing weight.  What’s more, it is known that adolescents who develop eating disorders are more likely to have mothers who diet and are preoccupied with weight and shape.  This has been shown to be a greater problem for young people with diabetes who rely on insulin and experience resultant weight gain1.  It must be stressed, however, that families should not be held responsible for a young person’s eating disorder any more than they are responsible for her diabetes; instead, they should be helped to understand both illnesses and given strategies to improve the relational dynamics with the family member suffering from an eating disorder to the benefit of all (see below).

There are also characteristics intrinsic to the young person with diabetes which have been implicated in the development of eating disorders.  For example, diabetic girls whose personality types tended towards harm avoidance and who scored low on scales of self-directedness were shown to be more likely to have clinical or sub-threshold eating disorders2.

How can young people with diabetes and an eating disorder be treated?

Treating young people with diabetes and an eating disorder is complex and requires a multi-disciplinary approach from a team which includes experts in both the management of diabetes and of adolescent mental health.  Early intervention is key and this is why education of diabetic healthcare professionals is so important: if they can recognise the signs and refer quickly to a specialist eating disorder team, the chances of avoiding serious complications are considerably higher.   Inpatient care is likely to be necessary if complications have occurred and/or if there is significant malnutrition or uncontrollable behaviours.

In the inpatient or outpatient setting, the diabetes team has responsibility for monitoring insulin regimens and should be involved in nutrition counselling.  In some cases, a less rigid approach in insulin therapy and nutrition is advised because intense management forces a young person to think constantly about the effects of their intake, insulin and exercise levels on their blood glucose.  This thinking can become obsessive and lead to eating disordered behaviours.  It has therefore been proposed that “good” as opposed to “optimal” blood sugars are better in eating disordered patients3.  Clearly, it is also important that healthcare professionals working with a young person whose eating is disordered do not provide positive reinforcement about weight loss, even if this is their normal practice with other diabetic patients.

The eating disorder team is crucial in providing education about the eating disorder to the young person in treatment and to their family, in selecting appropriate therapies and in medication management.  It has been proposed that both individual and family therapy are important in helping diabetic young people in their recovery from an eating disorder.  Individual therapy can assist the young person to find healthier coping strategies whilst family therapy can help the family to develop more functional ways of relating to one another and to learn to cope with the sense of grief which comes from learning that a family member has a long term illness.  There have been few studies considering the impact of specific therapy modalities in patients with coexisting diabetes and eating disorders, but “psycho-education” – a method of teaching the young person coping skills for living with chronic disease – has been shown to reduce disordered eating3.

In summary, the combination of diabetes and disordered eating is commoner than one might think, and has complex origins.  Though potentially lethal, it is possible for both illnesses to be managed by an appropriate multidisciplinary team, and better outcomes are achieved where there is early intervention.

References

  1. Daneman, D et al: Eating disorders in adolescent girls and young adult women with Type 1 Diabetes. Diabetes Spectrum 2002;15(2):83-105
  2. Grylli, V et al: Eating disorders and eating problems among adolescents with Type 1 Diabetes: Exploring relationships with temperament and character. Journal of Pediatric Psychology 2005;30(2):197-206
  3. Kelly, SD et al: Disordered eating behaviours in youth with Type 1 diabetes. The Diabetes Educator 2005;31:572-583

 

Last Reviewed By: Jacquelyn Ekern, MS, LPC on May 7, 2013

Page last updated: May 7, 2013
Published on EatingDisorderHope.com, Eating Disorder Resource