8/7/2015

Diabetes and Disorders Lorraine Platka-Bird PhD, RD, CDE “Having is the easiest way to have an Director of Center for Hope of the Sierras Reno, NV . I can go out to eat with my friends, eat anything I want, and purge during the without anyone knowing

I am doing it.”

The Basics DSM-V Classifications

• Eating disorders • Association between diabetes and eating disorders

• Inside the mind of a diabetic with an eating Binge Eating Disorder disorder/what they want us to know Other Specified Feeding • Treatment or Eating Disorder • Other considerations

Development of Eating Disorders (Psychological )

• Hunger: Physiological need for . • Emotional connection with food as a positive experience starts at birth. • Eating for reasons connected with boredom, • Appetite: for food whether or not , anxiety, sadness, etc., or eating to hunger is present. distract or escape can be learned and reinforced over time (eating to avoid negative ). • Overeating/bingeing for reasons other than • Satiety: Feeling of fullness and/or hunger can become habitual. satisfaction. • NOT eating for emotional reasons can follow similar pattern.

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Psychological Effects of (restriction) Restrict/Overeat or Binge Cycle or Menu Plan (restriction) • Feelings of deprivation often leads to cravings (both biological and psychological). • Feelings of guilt due to eating forbidden hunger gain weight . • Preoccupation with food. continue to eat (appropriately) binge • Obsessive, compulsive thinking. • Use of food (overeating/bingeing and/or restriction) as a coping mechanism (food guilt all or nothing mentality gains more emotional power).

Hunger/Satiety Scale in People with Normal Hunger/Satiety Scale Traditional Eating Disorders • More difficult to identify moderate hunger and comfortable fullness. • By the time hunger is identified, it tends to be 0___ 3____ 7___ 10 more extreme. Hunger Fullness • More difficult to eat moderately when hunger is more extreme. • Some combination of restrict/binge/purge cycle present in those with eating disorders.

Development of Eating Disorders in Patients with Diabetes “Diabulimia”

• Patients may already have an eating • Not recognized in DSM-V as a diagnosis. disorder or disordered eating prior to • Diabulimia describes an eating disorder diabetes diagnosis. behavior associated with . • Patients may also develop an eating • Patients deliberately skip or reduce disorder after diabetes diagnosis. dose for the purpose of losing weight or – What percentage had symptoms of the eating preventing weight gain. disorder but no diagnosis before they were • Results in , glucosuria, diabetic diagnosed with diabetes? , , and rapid .

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Potential Warning Signs for “Diabulimia” Traditional Eating Disorders • Other eating disorder behaviors are often present (restriction, bingeing, purging, over- • Weight loss (often despite increased or no exercising, judging self-worth by weight/body change in food intake). size, etc.). • Weight fluctuations. • Symptoms of an eating disorder may be sub- • Hunger denial, secretive eating, or bingeing. clinical. • Restricting or eliminating certain foods or food • Diabulimic patients suffer the consequences of groups (“safe” and “forbidden” food lists). not taking care of a potentially life-threatening • Inappropriate use of diet pills, diuretics, medical condition in addition to the risks laxatives, enemas, ipecac, caffeine, hot or cold associated with traditional eating disorders. beverages, sugar-free gum, etc.

Warning Signs for Traditional Eating Warning Signs for Diabetes Related Disorders Eating Disorders

• , , lethargy. • Poor metabolic control (hyperglycemia and/or • Excessive exercise. elevated HbA1c) despite reported • Preoccupation/obsession with weight, body- compliance. image and/or food intake. • Weight loss or weight maintenance despite • Being overly critical of appearance. unchanged or increased food intake. • (females). • Recurrent DKA. • Anxiety/depression/extreme mood changes. • Classic symptoms of diabetes: excessive urination, excessive , excessive hunger. • Self-hatred.

Why might diabetic patients be at Why are diabetic patients at increased risk for developing eating increased risk for eating disorders? disorders? • Onset of diabetes is often associated with weight • Contraindication of high carbohydrate foods when loss that diabetic does not want to give up. blood glucose levels are elevated. • Insulin treatment often leads to increased • Focus on numbers. hunger and weight gain, increasing likelihood of • Necessity of reading food labels. poor . • Need for ongoing close monitoring of diet, exercise, • Routine focus on weight at every doctor visit. blood glucose levels and insulin dosages leads to • Restrictive element of diabetic diet. obsessive thinking and unhealthy preoccupation with food and weight. • Classification of foods as “allowed,” “forbidden,” “good” or bad”. • Fear of bad experiences going low – eat to prevent or correct, then feel guilt about eating and fear that • Shame about food choices. eating will lead to weight gain.

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Why are diabetic patients at Why are diabetic patients at increased risk for eating increased risk for eating disorders? disorders? • Role of parents or others (“diabetes police”) in • Psychological issues associated with managing diabetes (control). diagnosis and management of long-term • Misconceptions/judgments of others: “You can’t eat illness (anger at diabetes). that, you’re diabetic!” (lack of understanding/education). • Diabetes diagnosis can contribute to • Need for control (controlling food and/or weight triggering factors that often lead to eating when one can’t control emotions or external disorders: low self-esteem, depression, situations). anxiety and . • Use as a coping mechanism (emotional disassociation). • Focus on exercise.

Increased Risks for Diabetic Patients Increased Risks for Diabetic Patients with Eating Disorders with Eating Disorders If manipulating insulin: If bingeing and/or purging: – Hyperglycemia – Episodes of both hyperglycemia and – DKA . – Elevated HbA1c levels – Earlier onset of degenerative complications of diabetes: – Earlier onset of degenerative complications of • Retinopathy (blindness) diabetes. • • Heart disease – All complications (physiological and • Nerve damage psychological) associated with bulimia. • Circulation problems – Higher early mortality rate than in diabetics without eating disorders

Inside the Mind of a Diabetic Patient Inside the Mind of a Diabetic Patient with an Eating Disorder with an Eating Disorder

• “If I am not taking my insulin, I can eat • “I know exactly how high I can bring my blood without feeling guilty because I know my sugar levels without going into DKA or body is starving”. needing to be hospitalized.” • “Hunger is legitimate when I am not taking • “If my blood sugars are so high that I crash, it my insulin.” is an accomplishment”. The eating disorder says, “Look how strong you are!” • “The more I eat, the higher my blood sugar will go and the more weight I will lose”. • “I can function at blood sugar levels that others would be hospitalized for. I am invincible!”

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Inside the Mind of a Diabetic Patient Inside the Mind of a Diabetic Patient with an Eating Disorder with an Eating Disorder • “If my blood sugar levels get so high that I • “The less my team knows about eating start vomiting, it is good because I am getting disorder, the easier it is to get away with it.” rid of sugar and my blood glucose levels will • “My endocrinologist who picked up on the go down.” fact that I was not taking my insulin is really • “Eating carbs before or after exercising smart, so I went to a different endocrinologist. defeats the purpose of the exercise” My new endocrinologist should have asked • “If I am following all of the rules that a “good” for my records!” diabetic follows, I am also following all the rules that my eating disorder dictates.”

What do they want us to know? What do they want us to know?

• Eating disorders can occur at any age. • “Thoughts of a diabetic with an eating disorder are not different than thoughts of a • For some teenagers, not taking insulin is non-diabetic with an eating disorder. We just simply about wanting to be like everyone have another tool.” else. • Treating someone with diabetes and an • Don’t use scare tactics. eating disorder is a balancing act. You can’t • “Don’t just assume I need more insulin if my apply the same principles you use with a numbers are high. Ask me more questions.” diabetic who doesn’t have an eating disorder. • “Don’t put so much focus on my weight.”

What do they want us to know? What they want us to know? • Diabetics can eat like people without diabetes, as long as they dose. • Exchange systems can fuel the eating • “Don’t tell us we can’t or shouldn’t eat certain disorder, contribute to all-or-nothing thinking, foods--it fuels the eating disorder.” lead to a of failure and “what difference • Carb cravings--especially for sugar--are does it make?” thinking in people with or at drastically higher when not taking insulin, as risk for an eating disorder. compared to carb cravings when just running • Trying to treat the diabetes without treating low. the eating disorder is like putting a band aid – Most say that the most common craving that they on a bullet wound. have is for soda.

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What do they want us to know? Goals

• “You, as the professional know the protocol, • Restore hunger scale to normal range. but if you don’t have diabetes you don’t know • Develop ability to appropriately interpret and how it feels.” respond to physiological hunger: • “I need my whole team to be on the same – Decreases urges to restrict and/or binge. page.” – Helps patients recognize when they are wanting to • “DON’T GIVE UP ON ME!” eat for reasons other than hunger.

Goals Intuitive Eating and Diabetes

• Give permission to eat freely. Accept one’s • Meal exchanges can reinforce the rigidity and food behaviors without self-judgment restrictive tendencies of the eating disorder. • Hunger is normal. • Intuitive Eating allows each individual the • Eating in response to hunger should not lead to flexibility to decide the best eating plan for self-criticism. him/herself. • It is ok to eat foods one likes. – Emphasis on using hunger, appetite and satiety to • Accept body at natural weight based on guide food choices. genetic predisposition. – Appropriate insulin dosing allows the diabetic patient freedom and flexibility in food choices.

Challenges: Food Challenges: Food Should diabetics choose lower carbohydrate • How do we talk about high carb foods? meal alternatives when blood glucose levels are higher and or choose sugar-free/no • What do we recommend about label reading? sugar added foods for or snacks? • Label reading is contra-indicated for the eating disorder patient but integral to diabetes protocol. • Appropriate for diabetes management. • How do we know when the decision is driven by the eating disorder rather than a desire to regulate blood glucose levels? • How do we recommend lower carbohydrate options without triggering the patient?

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Challenges: Exercise Challenges: Insulin • Unhealthy exercise behaviors may develop as an integral part of the eating disorder. • How do we approach a diabetic who we think – Focus on burning calories may not be taking insulin for the purpose of ? • May develop a pattern of compulsive over- exercise (moving target). • May lead to all-or-nothing thinking and yo-yo exercise, similar to what occurs with dieting. • Beneficial for insulin effectiveness and blood glucose management.

Treatment Related Questions Treatment Related Questions

• How do we screen for eating disorders in • What is the influence of patients’ desire to patients with diabetes? please their endocrinologists and/or diabetes – HbA1c may not be higher than expected. educators? – Patients unlikely to volunteer information. – Eating disorder patients are often people-pleasers. – It is beneficial for endocrinologists and diabetes – Patients are often reluctant to report if they are not educators to know what questions to ask. taking insulin as prescribed and/or are engaging in other eating disorder behaviors. – Eating disorders are strongly linked to shame, embarrassment and secretiveness.

Treatment Related Questions Treatment Related Questions

• Is the reason that some patients with • Do current methods of diabetes education diabetes develop eating disorders based on increase the incidence of eating disorders in the predisposition of the patients, the way we at-risk patients? educate about diabetes management, or is it – Labeling good foods/bad foods. some combination of both? – Emphasis on numbers. – Rules, rigidity and fear-based motivation tactics can – What makes some patients more vulnerable? lead to shame, guilt, hopelessness and increased – What modifications might we need to make in risk for eating disorders in some patients. diabetes education?

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Treatment Related Questions

• How do we educate diabetic patients who are at risk for eating disorders? • How do we identify which patients are at- risk? • Current methods that are effective for patients at negligible risk for eating disorders might be contra-indicated for people who are higher risk. • Is this the tip of the iceberg?

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