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Eating Problems Chapter 8 Eating Problems Key Messages • The term “eating problems” encompasses both “sub-clinical” disordered eating behaviors and full syndrome eating disorders. • Disordered eating behaviors include food restriction, compulsive and excessive eating, and weight management practices, which are not frequent or severe enough to meet the criteria for a full syndrome eating disorder. • Eating disorders include several diagnosable conditions (e.g., anorexia nervosa, bulimia nervosa, and binge eating disorder), which are characterized by preoccupation with food and body weight, as well as disordered eating behavior, with or without compensatory weight control behaviors. • Among people with diabetes, the full syndrome eating disorders are rare. The most common disordered eating behaviors are binge eating and insulin restriction/omission, but prevalence is not well established. • Eating problems in people with diabetes are associated with suboptimal diabetes self-management and outcomes, overweight and obesity, and impaired psychological well-being. Eating disorders are associated with early onset of diabetes complications, and higher morbidity and mortality. • A brief questionnaire, such as the modified SCOFF adapted for diabetes (mSCOFF), can be used as a first step screening questionnaire in clinical practice. A clinical interview is needed to confirm a full syndrome eating disorder. • Effective management of eating problems requires a multidisciplinary team approach, addressing the eating problem and diabetes management in parallel. Practice Points • Ask the person directly, in a sensitive/non-judgmental way, about eating behaviors and attitudes towards food, insulin restriction/omission, and concerns about body weight/shape/size. • Be aware not to positively reinforce weight loss or low A1C when eating problems are (likely) present. • Be aware that acute changes in A1C and recurring diabetic ketoacidosis could indicate insulin omission and may be an alert to the presence of an eating disorder. Diabetes and Emotional Health | 129 EATING PROBLEMS How Common Are Eating Problems? Eating disorders (anorexia nervosa, bulimia nervosa, and binge eating disorder) Type 1 diabetesa,1–3 Type 2 diabetes2,4 Disordered eating behaviors Type 1 diabetes5–8 Type 2 diabetes9–11 WHAT ARE Eating Problems? Eating Disorders › Bulimia nervosa: characterized by recurrent These comprise a group of diagnosable conditions, episodes of binge eating, at least once a week for characterized by preoccupation with food, body weight, three months, and compensatory weight control and shape, resulting in disturbed eating behaviors with behaviors. Similar to anorexia nervosa, weight or without disordered weight control behaviors (e.g., and shape play a central role in self-evaluation. In food restriction, excessive exercise, vomiting, and contrast to anorexia nervosa, weight is in the normal, medication misuse).2,3 They include: overweight, or obese range. › › Anorexia nervosa: characterized by severe Binge eating disorder: characterized by recurrent restriction of energy intake, resulting in abnormally episodes of binge eating, at least once a week for low body weight for age, sex, developmental stage, three months. People with a binge eating disorder and physical health; intensive fear of gaining weight do not engage in compensatory behaviors and are or persistent behavior interfering with weight gain; often overweight or obese. and disturbance in self-perceived weight or shape. › Other specified or unspecified feeding or eating There are two subtypes: disorders: characterized by symptoms of feeding • restricting subtype, with severe restriction of or eating disorders causing clinically significant energy intake distress or impact on daily functioning, but that do not meet the diagnostic criteria for any of • and binge eating/purging subtype, with the disorders. Specified eating disorders are, for restriction of food intake and occasional binge example, “purging disorder” in the absence of eating and/or purging (e.g., self-induced binge eating, and night-eating syndrome. vomiting, misuse of laxatives, etc.). a Based on young women only. 130 | Diabetes and Emotional Health EATING PROBLEMS The complete diagnostic criteria for the above- Although eating disorders develop typically during mentioned eating disorders can be found in the adolescence, they can develop during childhood International Statistical Classification of Diseases and or develop/continue in adulthood; they occur in Related Health Problems, 11th revision (ICD-11)12 and both sexes.14 For example, binge eating disorders Diagnostic and Statistical Manual of Mental Disorders, are more prevalent in middle-aged individuals than 5th edition (DSM-5).13 The criteria for eating disorders in youth and young adults, and there is no female were revised in the fifth edition of the DSM.13 preponderance.15 BOX 8.1 Prevalence of Eating Disorders and Disordered Eating in Adults with Diabetes Is Not Yet Well Established Diabetes is likely associated with an increased risk In addition, most studies have included predominantly of eating problems. However, published prevalence female adolescents or young adult women, and data are inconsistent, with some studies showing no sample sizes are small.17 difference in rates compared to a general population, Due to such limitations, the evidence of eating 2 and others reporting higher rates. problems in adults with diabetes is limited and The inconsistencies are largely due to the findings should be interpreted and generalized with methodology used (e.g., measures and inclusion caution. criteria), for example: Though the current evidence base is limited, it has › Data are collected typically with general eating been established that: disorder questionnaires, and the findings are not › the prevalence of anorexia nervosa in female necessarily confirmed with a clinical interview or adolescents and young women with diabetes is examination. low and not more prevalent than in the general • These questionnaires tend to inflate the population18 estimated prevalence of eating disorders and › and people with diabetes are more likely to disordered eating behaviors in people with present with periodic overeating, binge eating, and 1,3,9 diabetes. The focus on diet that could be compensatory weight control behaviors,19 with considered problematic for people without more frequent and severe behaviors likely to meet diabetes may be a necessary aspect of self- criteria for a full syndrome eating disorder such as care for people with type 1 diabetes. Thus, bulimia nervosa or binge eating disorder. some of the items in general eating disorder questionnaires are not appropriate for people Future studies about eating behaviors should include with diabetes. men, because, as is true in women, binge eating is more common in men with type 2 diabetes than it is • Apart from overestimating prevalence, the in men without diabetes.3,20 questionnaires are not sensitive enough to identify diabetes-specific compensatory behaviors, such as insulin restriction/omission.16 Diabetes and Emotional Health | 131 EATING PROBLEMS Disordered Eating Behaviors These are characterized by symptoms of eating BOX 8.2 Eating Styles disorders but do not meet criteria for a full syndrome Certain eating styles are associated with difficulties eating disorder. For example, binge eating episodes in adjusting or maintaining healthy eating habits and occurring less frequently than specified for a diagnosis weight; they may put people with diabetes at risk of of bulimia nervosa or binge eating disorder. However, if developing an eating problem.18 For example:23 left untreated, disordered eating behaviors can develop › Emotional eating (in response to negative into a full syndrome eating disorder. The following emotional states, such as anxiety, distress, and disordered eating behaviors can present in isolation or boredom) provides temporary comfort or relief as part of an eating disorder:13 from negative emotions, as a way of regulating › Binge eating: includes eating in a two-hour period mood. It is associated with weight gain in adults an amount of food that most people would consider over time24 and tends to be more common in unusually large, plus a sense of loss of control when people who are overweight or obese.25 overeating. It is a symptom in all three main full › External eating (in response to food-related syndrome eating disorders (binge eating/purging cues, such as the sight, smell, or taste of food) subtype of anorexia nervosa, bulimia nervosa, and accounts for approximately 55% of episodes binge eating disorder). It can occur in response to of snacking on high-fat or high-sugar foods in restrained eating (e.g., rule-based/restrictive eating), people who are overweight or obese.26 emotional cues (e.g., eating when distressed or bored), and external cues (e.g., eating in response to Emotional and external eating may increase the the sight, taste, or smell of food) (see Box 8.2). likelihood of snacking on high-fat or high-sugar foods,26 higher energy intake,27 overeating and › Compensatory weight control behaviors: binge eating,28 and nighttime snacking.29 include deliberate acts to compensate for weight gain following overeating or binge eating. For › Restrained eating (attempted restriction of food example, self-induced vomiting, excessive/driven intake, similar to being on a diet, for the purpose exercise, medication misuse (e.g., laxatives or of weight loss or maintenance) may be an diuretics), omission or restriction
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