The Impact of Co-Existing Diabetes and Disordered Eating
Mar 21, 2024, 15:21 PM
By Janice Baker, MBA, RDN, CDCES, CNSC, BCADM
I first heard the word “diabetes” when I was about seven years old. I remember my grandpa turning down the Oreo cookie I offered him saying, “I can’t eat that, I have diabetes” (around 1966 for perspective). I noticed him taking his daily pill (tolbutamide), and other than taking long walks with him, I don’t remember much else about any diabetes self-care — likely because there were minimal choices or knowledge and not many formal diabetes education options at the time.
My father was diagnosed with diabetes in the late 1970s when I was in high school. Noticing the profound thirst, abrupt vision changes and mood swings, along with dramatic weight loss due to muscle wasting and dehydration, I had no idea what a traumatic medical assault this was. As he started on insulin injections with vials and syringes, with no glucose meters available at the time, I also saw the large multiple page “Exchange List of Foods for Diabetes” book on his desk, likely never opened. While my dad continued eating as he preferred, including frequent fast food and large portions of soda to quell his continued (likely hyperglycemia induced) thirst, being familiar with the Exchange List book helped me land my first local community hospital job as a diet technician during my first year of college.
Fast forward to my internship working at a diabetes summer camp for children, preparing foods and making sure our kids had their “meal cards” when at the dining hall for all three meals. We sat with them and carefully monitored their portions and servings to fit a prescribed plan. Looking back, this certainly took much of the fun and spontaneity out of the camper’s mealtimes. Along with this, the teen boys continued to be reprimanded for breaking into the kitchen almost nightly due to unsatisfied hunger and the likely underestimation of energy needs that a growing teen truly needs (1,800 calories per day is about one-third to one-half of the needs for many active and growing teens).
Little did I realize that these observations and experiences would be part of the connections I made between the coexistence of diabetes–whether Type 1, Type 2, gestational, or even prediabetes and disordered eating patterns. The relentless focus on “good and bad” foods, underestimation of calorie needs, minimizing the importance of joy and pleasure of eating vs. the numbers, and lack of understanding of the profound impact of hormonal regulation of blood glucose. Hunger and satiety, along with social and cultural influences on appearance ideals, can set up a perfect storm to trigger a dysfunctional, dysregulated and disordered relationship with food.
It's important to consider that up to 20% of those with diabetes may have some form of eating disorder. Those with higher weight bodies tend to have higher rates of eating disorders and Type 2 diabetes, and these individuals are more likely to be recommended weight loss interventions — further exacerbating a binge/restrict cycle in many cases. Eating disorder screenings in primary care and endocrinology practices are typically not done. And despite good intentions, health care providers sometimes offer weight stigmatizing and conflicting messages that add to the often already internalized shame, blame and stigma for the patient’s medical status.
Consider why people with diabetes and a diagnosed or undiagnosed eating disorder are often confused: For diabetes management, they are often told to restrict certain food groups — specifically carbohydrates, as well as lose weight, focus on numbers such as the A1C, blood glucose, calories and activity trackers, etc. and to avoid trusting cravings or pleasure from food. In contrast, for eating disorder recovery, the message is that all foods fit. There is no such thing as “bad foods,” don’t try to lose weight, stop thinking about numbers, eat intuitively, eating with pleasure and trusting your body. Additionally, the use of restrictive diets, newer diabetes weight loss medications such as the GLP1/GIP class, bariatric surgery and other therapies may contribute to nutrition deficiencies, malnutrition (which can occur in any size body), gastrointestinal side effects and loss of lean body mass/sarcopenia. Thus, the quality of life for these individuals may be further impacted.
In individuals with Type 1 diabetes, the temptation for and praise for weight loss from insulin omission can be powerful, often even at the risk of serious medical consequences. And the intense fear of weight changes from nutrition rehabilitation, fluid balance shifts during recovery and repair of tissues during treatment is highly stressful and requires specialized and ongoing medical and mental health support. Psychoeducation not only for the individual but for family and caregivers is also essential as many have outdated and incorrect information about nutrition and diabetes care. Social and medical trauma isn’t uncommon and dealing with data and metrics can also be overwhelming.
While each person we see has a unique and individual story regarding their journey with diabetes as well as their relationship with food and their body, diabetes care and education specialists have an incredibly important and impactful role to play in supporting people with diabetes considering increasingly recognized biopsychosocial influences and determinants of health. Seeking continued education from reliable sources on the dual diagnoses of diabetes and eating disorders is an essential part of our professional development and likely will become more important as our population ages, as many years of weight management approaches, therapies and cultural pressures of appearance ideals continue to add to the influences and pressures on our patients.