and Eating Disorders

Ami Marsh, MS, MFT, LCADC Diabetes and Eating Disorders

“Having diabetes is the easiest way to have an . 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 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 . • 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, 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

• (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

• , , lethargy. • Excessive exercise. • Preoccupation/obsession with weight, body-image and/or food intake. • Being overly critical of appearance. • – 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 ( 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 . • 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) • • 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 multi- disciplinary 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, , 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, self- empowerment, 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