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Type 1 diabetes, disordered eating and diabulimia

Sep 29, 2010

Have you ever worked with a young lady with type 1 diabetes who has unexplained elevations in A1C, repeated problems with DKA intermixed with fear of weight gain?

Since the 1970s, there have been reports of disordered eating among patients with type 1 diabetes, with mixed results on the frequency. In a recent large multi-centered, case-controlled study of girls aged 12-19, eating disorders were twice as common in girls with diabetes then in their peers without diabetes (Jones et al, 2000).

Speculation continues on the etiology: be it the required focus on eating and counting foods; the effects of a chronic medical condition on self image; or the increased average weight associated with type 1 diabetes compared to controls. Common sign of disordered eating in young women with type 1 diabetes include: poor adherence to one or more treatment regimens, poor metabolic control with elevated A1C; recurrent symptoms of hyperglycemia, recurrent episodes of ketoacidosis, growth retardation and pubertal delay (Turner and Peveler, 2005). It is common enough that there are several inpatient centers in the country that now specifically treat the dual conditions of eating disorders and type 1 diabetes.

Routine questions to consider when working with the at risk population include: binge eating episodes, intentional omission of insulin, laxative use/abuse, dieting for weight control, and any purging behavior. Probably of gravest concern is the opportunity to control weight by deliberate insulin omission, inducing hyperglycemia and glycosuria. Studies report frequency of insulin omission from 13-39% of preteens through young adulthood. In one study, there was a threefold increase in the risk of diabetic retinopathy with persistent eating disorders. Retinopathy was more closely related to disordered eating status than duration of diabetes (a well documented marker) (DCCT Research Group, 1993).

We, as diabetes educators, need to think about the possibility of a co-existing condition of eating disorders or intentional insulin omission when working with teens with type 1 diabetes. Interestingly, I have a delightful teacher with type 1 diabetes that I work with who states “don’t all teens with type 1 diabetes have an eating disorder? I sure did!” I have a number of patients in my practice who admit to disordered eating behaviors, however, I believe there are many more that are practicing bulimic behavior. Hopefully, I will take the time to ask the questions that may open the door to recognition and effective treatment.

What screening tools have you used in your practice? Do you have a team approach? Do you refer dual disorders to another practitioner? Share your stories, so we can all learn from them.


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  1. Oct 28, 2010

    Dear Carla-I am so thrilled that you addressed this since it is not something that we talk about very often, yet with rates in people with type 1- ranging from 30-50% & more-we should be screening everyone. After having a family member with type-1 go thru this last year we found it very hard to be diagnosed then to find a center that treats Diabulimia. After having gone thru this successfully I did a Journal Club focus on Eating Disorders in type-1 with our practice of Endo.'s & CDE's. I did find screening tools-i.e. The Eating Attitudes Test (EAT-26) & we did compile a list of local Therapists that treat Eating Disorders. At the AADE conference there was the The Center for Hope of the Sierra's that had a table with great information as well. I would be interested too in how other practices are screening for this. I find it interesting that we do not talk about this with other professionals yet we need to!!
  2. Oct 06, 2010

    Just today I saw a young type 1 patient for diabetes education. She has a history of manipulating her insulin for increased weightloss and sees a counselor every two weeks. Her average blood sugar is in the upper 100s to lower 200s and we have repeatedly advised her to increase her basal insulin. Today she still has not made any progress toward better control and got very tearful when I addressed this issue. I encouraged her to confide in someone like her parents or a friend for moral support, but she doesn't believe anyone would understand her. Since she refuses to increase her insulin, I would like to give her more suggestions to help her with her blood sugars, but I am afraid to ask her to limit her carb intake or increase exercise, for that may worsen her eating disorder. Any suggestions?
  3. Oct 01, 2010

    If there are screening tools, I'd love to know. We generally just notice that the A1c has been going up, and the weight going down, then open discussion about the possibility.
  4. Sep 30, 2010

    I used to work in the eating disorder field and I am also a CDE and it is more prevelent than you think. I find few MD identify it, even when you bring it to their atttention they don't acknowledge and many cases go untreated. I always assess for it with my repeat DKA females. It is not just teens, I see it in young adult woman too who feel pressured to be thin. Many know just what to do to keep themselves out of DKA but continue with elevated BG with weight loss. I always try to refer them for counselling if possible with a knowledgable eating disorder specialist who is also experienced with diabetes.

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