What You Should Know About Eating Disorders
by Ivy Marcus, Ph.D., C.D.E.
Since the early 1980's, there has been a rapidly growing awareness of the prevalence and consequences of eating disorders. It is only more recently, however, that the interaction of disordered eating and diabetes, especially Type 1 diabetes, has become a focus and concern. If you or a loved one has an eating disorder, it is important-and possible-to get help. This article describes eating disorders, their connection to diabetes, and what types of help are available.
Types of Eating Disorders
The three main eating disorders are bulimia nervosa, anorexia nervosa, and binge eating disorder. Bulimia nervosa is characterized by recurrent episodes of binge eating, or eating in a relatively short time period (usually two hours) an amount of food that is larger than most people would eat in similar circumstances. Other features of bulimia include feeling a lack of control over one's eating during bingeing episodes, and repeatedly engaging in behavior to prevent weight gain after binges such as self-induced vomiting, abuse or misuse of laxatives, diuretics (drugs that increase urine production), enemas, or other drugs (including insulin), fasting, severely restrictive dieting, or excessive exercise. Persistent overconcerns with and self-evaluation based on weight and body shape are typical, as well. A depressed mood and self-deprecating thoughts often follow bingeing episodes.
Two types of bulimia exist: One is the purging type, in which self-induced vomiting or laxatives, diuretics, or enemas are used to prevent weight gain following binges. The other is the nonpurging type, in which other behaviors are used to prevent weight gain following binges. The misuse, omission, or alteration in dosage of insulin falls into this category. A diagnosis of bulimia is made when the bingeing and the unhealthy behaviors to prevent weight gain both occur, on average, at least twice weekly for at least three months. In spite of their eating habits, people with bulimia usually maintain a normal body weight, although some may be slightly overweight or underweight.
Anorexia nervosa is defined as a refusal to maintain one's body weight at or above minimal normal standards for age and height, accompanied by an intense fear of gaining weight or becoming fat, a disturbance or distortion in body image, and amenorrhea, or the absence of at least three consecutive menstrual periods (in girls and women). Two types of anorexia exist: the restricting type, in which no regular bingeing or purging behavior occurs, and the bingeing/purging type, in which regular bingeing or purging occurs.
Binge eating disorder is characterized by recurrent episodes of binge eating. Usually, the bingeing episodes involve rapid eating, eating until one feels uncomfortably full, eating large amounts of food despite not feeling physically hungry, eating in solitude to avoid embarrassment over the amounts eaten, and feeling disgusted with oneself, depressed, or guilty after overeating. People who binge do not enjoy their food during a binge; instead, they tend to experience marked distress. No regular use of behaviors to avoid weight gain occurs in binge eating disorder, and the frequency of the binges is lower than in cases of bulimia. While bulimia and anorexia affect more people with Type 1 diabetes than people with Type 2 diabetes, binge eating disorder may affect both groups equally. But so far, little formal research has been conducted on binge eating disorder.
Eating disorders are becoming quite common in American society. It is estimated that up to 1% of teenage girls have anorexia. The rate of bulimia is reportedly as high as 19% in the female population. And the rate of binge eating appears to be very high, especially among young women. In some studies of certain populations, up to 86% of the group studies has been found to binge. Although binge eating has certainly been around for a long time, it has only been officially recognized by the medical community as an eating disorder since 1994. More research is needed on binge eating disorder to understand its causes and prevalence in the general population and among people with diabetes.
It is currently understood that eating disorders are the end result of a variety of developmental factors. Psychological, societal, biological, and familial factors all contribute in varying degrees to the development of an eating disorder.
Although many people have mild eating disturbances, a full-fledged eating disorder is a serious and potentially life-threatening condition that needs to be treated. Both medical and psychological consequences can result. Some of the possible medical consequences of an untreated eating disorder include amenorrhea (cessation of menstruation, indicating a shut-down of hormonal regulating systems in the body), osteoporosis, dehydration, irregular heart rhythms, tears in the lining of the esophagus and stomach, constipation, tooth cavities, swollen parotid glands (a type of salivary gland), chemical imbalances possibly leading to cardiovascular problems, and obesity. Possible psychological consequences include depression, anxiety, loss of concentration, low self-esteem, and social isolation. These serious issues become further complicated when a person also has diabetes.
People of all ages, races, and ethnicities and of both genders can struggle with eating disorders, but women are affected on a much more frequent basis. Let's take a look at why this is the case.
Social Factors. Despite the multifaceted nature of the development of eating disorders, it is generally believed that dieting or attempts at dieting are associated with the evolution of these disorders. Is it no wonder, then, that women appear to suffer from eating disorders to the degree that they do?
In any society where the pursuit of slimness becomes a way of life, eating disorders becomes widespread. Rigid dieting and severe restriction of calories inevitably lead to a preoccupation with weight, shape, and size, and also to increased hunger. This magnified hunger almost always results in an episode of overeating or bingeing, which in turn prompts some sort of behavior to prevent weight gain and to quell the emotional distress accompanying the deviation from the diet. A cycle is easily created, in which the person alternates between strict dieting and compensation for deviations from that diet. In cultures that believe that women can never be too thin, it is easy to understand how a full eating disorder can develop.
Family Issues. Familial issues also play a role in the development of eating disorders. The methods family members (especially parents and siblings) use to express feelings-and the way they teach children to express feelings-become key in how individuals learn to experience, communicate, and cope with difficult emotions. For example, if a family teaches a young girl-either directly through words or indirectly through body language-that it is unacceptable to feel or express anger, that girl will not learn to express herself assertively and may instead learn to "stuff" her anger down with food. She will also learn to feel bad about herself and to believe in the inappropriateness of her negative feelings. However, appropriate assertive behavior is crucial for a person's well-being, self-esteem, and ability to negotiate relationships in life.
Family issues can also arise around expectations for achievement, especially if those expectations are unrealistic and perfectionistic in nature. For example, it is unrealistic to expect a child to get straight A's throughout his entire academic career; this expectation sets up a rigid and virtually impossible goal. It is realistic, on the other hand, to expect a child to strive for the best grades he can get; this expectation focuses on effort and leaves room for normal human variation.
Family dynamics can also come into play. In some families, relationship alliances, or unhealthy partnerships in which some family members band together and leave others out, arise. For example, Mom may be the disciplinarian when it comes to food choices, while Dad and daughter Susie ally and sneak off together to eat "forbidden" foods. Although Susie may initially enjoy these secret snacks, ultimately this system works well for no one, and certainly not for Susie's eating habits.
Struggles for control in families, and the ways in which parents foster independence and autonomy in their children can also be related to the development of eating disorders. Modeling, or the learning of a behavior through the observation of others, enters into the equation, too. For example, by watching his mother or father eat when confronted with stressful situations, a child may learn to do the same to anesthetize the pain of stress. Or he may learn to diet at a very young age, just as he observes a parent doing. Many people learn to eat as a coping strategy simply because they never learned other, more productive tools for coping.
Children also may learn to be critical of their bodies or to judge and/or value themselves based upon their appearances rather than on their internal, inherent self-worth. This unfortunate "lesson" is usually the net result of many different variables in a child's life, but parents can encourage a more positive self-image in their children by praising, rewarding, or focusing on valued behaviors and intentions rather than appearances. Girls in particular are vulnerable to absorbing the notion that their worth or value is tied into their appearance, specifically to their body weight, size, and shape. In addition, the belief that men are only interested in women if their appearance is "adequate" is oftentimes embedded in cultures and families.
Psychology and Biology. Psychological issues stem from a combination of the above-mentioned social and familial influences. Many people with eating disorders, because of their propensity toward perfectionism, and nonassertiveness, become depressed, anxious, and preoccupied and suffer from low self-esteem. They may also have a biological weight "set point" (a genetically determined range for body weight) that is above their liking, thereby contributing to disdain for their bodies.
The Diabetes Connection
Women with diabetes seem to be at particular risk for developing an eating disorder, perhaps because of the central roles that weight and food take on in the life of almost anyone with diabetes. Oftentimes, one of the first symptoms of Type 1 diabetes is weight loss-something a girl in our society may welcome with open arms. However, once the diagnosis of diabetes is made and a person begins taking insulin, he or she usually regains the weight that was lost, a development that may cause dismay in some girls.
Developing a preoccupation with food, calories, carbohydrates, and controlled eating habits can be a natural by-product of learning to manage one's diabetes. But such a mindset can prepare the stage for an eating disorder to emerge. If an adolescent girl or young women tries to compensate for even minor episodes of overeating with excessive or unhealthy behaviors and succeeds in her attempt, she may be seduced into believing that she has found a method to eat whatever she wants and still not gains weight. Unfortunately, this can rapidly evolve into a vicious cycle, propelling the girl into emotional quicksand.
Contributing to the problem is the fact that weight loss for a person with diabetes is usually viewed as a positive event and is assumed to be the result of tight diabetes management or control. However, this is not always the case. In fact, one of the physical changes observed among those practicing "tight control" in the landmark Diabetes Control and Complications Trial was weight gain, not loss. Therefore, friends, family members, and even health-care providers need to be wary of the effect that their questions and compliments about weight loss may have on a person. It is better to comment on healthy behaviors, rather than on resulting weight loss. For example, you might compliment a friend's efforts to exercise regularly. A doctor, rather than praising weight loss, might compliment a person's efforts to keep thorough blood sugar or food records. Or a concerned friend or doctor might ask a person who has lost weight how he or she feels about it, rather than declaring the weight loss either bad or good. AS we all know, listening to how a friend or child feels is often a more powerful tool than talking to that person.
People with diabetes may also discover an uncanny "trick": that decreasing or completely omitting their insulin doses, particularly after overeating or bingeing, not only prevents weight gain but promotes weight loss. Unfortunately, there are seriously dangerous side effects to this practice: extremely high blood glucose levels and a dramatically higher risk of complications. Recent studies have documented some of the risks inherent in the toxic blend of diabetes and eating disorders: poorer diabetes control, the increased likelihood of the presence of the protein albumin in the urine (a predictor of the risk of diabetic kidney disease), and a greatly increased risk of microvascular complications such as retinopathy, which can lead to blindness.
Another important risk factor for the development of an eating disorder in a person with diabetes is the sense of loss of control many people with diabetes experience as a result of having a chronic, high-maintenance disease. The illusion of being in total control of one's food can appear to be a panacea for such feelings. But the type of "control" wielded by a person with an eating disorder is indeed illusory. Allowing an eating disorder to dominate one's life is actually akin to giving up control and responsibility for one's food intake and well-being. Treatment for an eating disorder involves taking back that responsibility and control over food and health.
The families of girls with diabetes are often (understandably) very involved in their food intake and their lives in general. However, such involvement may increase these girls' risk of developing eating disorders. An eating disorder may be a girl's attempt at securing her separation and independence from her family. Parents of a child with diabetes have a difficult and unique challenge in that they must asses when and how to allow their child to take more responsibility for his or her diabetes while simultaneously balancing this with some supervision and guidance.
In summary, when eating disorders and diabetes coexist, they do indeed appear to feed on each other. This interaction typically results in a worsening of both conditions. More frequent hospitalizations for diabetes-related complications and an increased resistance to resolving the eating disorder are not uncommon. Despite the apparent gloominess of the situation, treatment is available, and individuals can get help.
If you or someone you know has diabetes and is struggling with an eating disorder, it is a good idea to get some professional treatment as soon as possible. Eating disorders tend not to go away on their own.
A variety of psychological therapies are sued for the treatment of eating disorders. One of these, cognitive-behavioral psychotherapy, is a well-researched type of treatment that has had a great deal of success in helping people change disordered eating and regain emotional well-being. This type of psychotherapy focuses on building new coping strategies to handle difficult emotions and situations. It helps to change eating habits and ways of thinking about food, weight, and body image, and it addresses the multitude of issue related to body image, weight, food, and gender in our culture. It also helps to impart an understanding of why a person thinks, feels, and behaves the way he does, based on his own individual personal history and experience. Ultimately, this therapy seeks to impart a sense of empowerment, control, and responsibility for one's eating behavior and related issues.
Psychotherapy can take place either individually or in a group setting. What's important is to find a mental health professional who is experienced in treating eating disorders and who is also trained and experienced in working with diabetes. Treating an eating disorder when diabetes is present is more complex than treating an eating disorder alone. To find such a therapist, try asking your endocrinologist for a referral. You can also contact your local American Diabetes Association chapter or the American Anorexia/Bulimia Association.
If you have an eating disorder and have not already worked with a certified diabetes educator and dietician, it might be a good idea to do so now. But keep in mind that all members of your healthcare team need to work with one another so that their efforts are coordinated properly. For example, it is essential that the eating disorder be treated first before ideal blood sugar control can be attained. Therefore, you and your dietician may need to wait until you have made some progress in therapy before focusing on your nutrition needs. If you are experiencing severe depression, your mental health professional may feel that a course of antidepressant drugs are appropriate at this time. If this is the case, all the members of your diabetes team need to know what drugs you are taking since some of them can have an effect on blood sugar, insulin dose, and/or appetite. Communication among all team members is vital for the most successful outcome.
If someone you know appears to be caught in the tangled web of an eating disorder, you can certainly encourage him or her to seek help. In doing so, however, be careful not to bring up the issue at emotionally sensitive times. Wait for a calm moment instead. It's also important not to be judgmental or critical in your approach, but rather to offer information on why it's a good idea to seek treatment and where to find it. For example, if you know that someone has been bingeing, you might say at a quiet, private moment, "It seems to me that you're struggling with some issues, perhaps related to food. Wold you like to talk about it? Maybe I can help." You might want to have some brochures or other written information on hand when you broach the subject. Ask if there's any way you can help, and leave the door open for future communication.
There's help out there, and the more quickly it is sought, and the more involved a person can become in conquering an eating disorder, the better chance that person has in avoiding serious medical complications caused by compromised diabetes self-care. If you need help, don’t be afraid to reach out and ask questions. You deserve to get the best and most appropriate treatment.