Eating disorders and diabetes

Prevalence, diagnosis, and treatment


In recent years, the Norwegian Diabetes Association has focused its attention on the emotional and practical problems which are often faced by individuals who live with diabetes.

Living with diabetes places extra stress on both the patient and their immediate family.

Diabetes affects both the body and soul.

In Autumn 2000, the medical council of the Norwegian Diabetes Association discussed issues

surrounding the co-occurrence of diabetes and eating disorders. The background for this

discussion was that both diabetes and eating disorders are regarded as serious illnesses which

demand comprehensive measures and are notoriously difficult to treat. Diabetes co-occurring

with an eating disorder represents a complex and complicated illness picture which can result

in dramatic physical and psychological consequences. Often the eating disorder is not

diagnosed until pronounced physical complications are evident. The medical council of the

Norwegian Diabetes Association concluded that a clear need existed to strengthen the

competence of health professionals in the prevention, diagnosis, and treatment of eating

disorders and diabetes. The council also determined that collecting epidemiological data on

the incidence and prevalence of eating disorders among persons with diabetes was warranted.

In January 2002, the medical council’s working committee established a working group with

the following mandate:

– Investigate the prevalence of eating disorders among individuals with diabetes.

– Develop guidelines for health care personnel on the prevention, diagnosis, and treatment

of comorbid eating disorders and diabetes.

The work commenced in May, 2002. The working group has done a thorough and pioneering

job. This paper describes practices considered to be widely-accepted professional norms, and

which are in accordance with professionally-recognised medical and psychiatric methods.

With the release of the paper, “Eating Disorders and Diabetes: Guidelines for Health Care

Personnel”, the Norwegian Diabetes Association hopes to contribute to raising competence in

the prevention, study, and treatment of eating disorders with diabetes, as well as improving

the quality of care offered to patients with comorbid eating disorders and diabetes. The

Norwegian Diabetes Association will, in collaboration with professional circles, review the

guidelines as and when new knowledge is acquired.

The Norwegian Diabetes Association would like to express its sincere thanks to the members

of the working group, and in particular, to Stein Frostad, who has assumed professional and

editorial responsibility. A note of gratitude is also extended to the reference group for their

useful contributions and constructive comments. We sincerely hope the guidelines’

conclusions and recommendations will help improve the quality of life for those suffering

from diabetes and eating disorders.

Yours sincerely

Norwegian Diabetes Association

supported by Helse og Rehabilitering

Anne Mette Liavaag


Oslo, August 2005

Contents Page

Introduction 4

Types eating disorders common among individuals with diabetes 5

Underdosing of insulin 5

Binge eating disorder and diabetes 6

Bulimia nervosa and diabetes 7

Anorexia nervosa and diabetes 7

Subclinical eating disorders and diabetes 7

Eating disorders and diabetes: a common combination 8

Eating disorders and diabetes: age distribution 8

Eating disorders and diabetes: complications 9

Signs of eating disorders with diabetes 9

Approaching a person with an eating disorder and diabetes 10

Active underdosing of insulin as a solution strategy 11

Food regulation as a solution strategy 11

Self-determination and recognition 11

The good helper – the good relation 12

The good tool 13

The process of change 13

Family work and family therapy 14

Treatment of underdosing of insulin 15

Treatment of binge eating disorder and diabetes 16

Treatment of bulimia nervosa and diabetes 16

Treatment of anorexia nervosa and diabetes 17

Prevention of eating disorders and diabetes 17

Overweight and focusing on weight 18

Weight gain in teenagers 18

Weighing 18

Normally no medical grounds for recommending weight reduction 19

When are there medical grounds for weight reduction? 19

How to carry out weight reduction? 19

Dietary guidelines in prevention and treatment 20

How to organise available treatment for diabetes so that

individuals with an eating disorder receive help? 21

Conclusions 23

References 24



Eating disorders are common among individuals with diabetes. Even less severe forms of

disordered eating can lead to significant disturbances in the regulation of blood sugar, which

increases the risk of diabetic complications.

Eating disorders occur across age groups and can present with both type 1 diabetes and type 2

diabetes. However, the most common and most serious comorbid presentation is among

young people with type 1 diabetes. In this paper, we have therefore focused upon the

assessment and treatment of young people with comorbid type 1 diabetes and eating


A number of studies exist regarding the treatment of eating disorders, but few, if any, have

focused upon the treatment of eating disorders among individuals with diabetes. Even though

a dearth of treatment literature exists, it is highly important that healthcare personnel

recognize and treat eating disorder symptoms among persons with diabetes given the high rate

of comorbidity and increased risk of diabetic complications. A majority of individuals with

less severe forms of eating disorders may likely benefit from methods deemed relatively easyto-

learn and implement. In the case of serious eating disorders, however, special competence

is typically required to ensure successful treatment.

In this paper, we describe motivational therapeutic methods for which health personnel

working with eating disorders are recommended to learn. In addition, we provide

recommendations to guide the treatment of serious eating disorders, such as anorexia nervosa,

and diabetes. By establishing a good level of collaboration, the physician or nurse and the

patient can work together to develop a strategy for how to best overcome the illness.

These guidelines are based upon existing literature regarding the treatment of eating disorders,

clinical observations and experience, and the committee’s considerations for what constitutes

best clinical practice.


Types of eating disorders common among individuals with diabetes

The diagnostic criteria for eating disorders are described in a paper from the Norwegian

Board of Health: ”Alvorlige spiseforstyrrelser; retningslinjer for behandling i

spesialisthelsetjenesten” (Serious eating disorders; guidelines for treatment in the specialized

health services) [1]. Eating disorders most frequently affect women, but approximately 10

percent of those with an eating disorder are boys and men [1].

Comorbid eating disorders and diabetes often presents unique problems. The most important

eating disorders seen in individuals with diabetes are discussed below.

Underdosing of insulin (insulin omission, insulin purging)

– Underdosing or omitting to inject insulin in order to lose weight

– High blood sugar produces reduced appetite, loss of sugar in the urine, and dehydration

Binge eating disorder

– Episodes of loss of control over intake of food. During these episodes, more food is

ingested than would be eaten in a normal meal. The binge eating episodes are not

accompanied by vomiting or compensatory actions to prevent weight gain. Criteria for

binge eating disorder include binge eating at least twice weekly, with a duration of at least

6 months. Many consider binge eating disorder to be a variant of bulimia nervosa.

Bulimia nervosa

– Binge episodes at least twice per week during the past 3 months.

– Loss of control of food intake during overeating episodes.

– “Purging” behaviors: attempted weight reduction through the use of vomiting, diuretic

medications, laxatives, excessive exercise, or underdosing of insulin.

– Undue influence of weight and shape on self-evaluation.

Anorexia nervosa (rare)

– Emaciation: BMI < 17.5 kg/m2; other weight criteria apply to pre-pubertal children

– Intense fear of gaining weight or becoming fat

– Significant body image disturbance, undue influence of body weight or shape on selfevaluation,

or denial of the seriousness of the current low body weight.

– Absence of three successive menstrual periods

Underdosing of insulin (insulin omission, insulin purging)

Unsurprisingly, underdosing of insulin is limited to individuals with insulin-treated diabetes.

If a person with diabetes reduces the recommended insulin dose, or omits insulin altogether,

blood sugar will rise. Sugar is thereby excreted in the urine and this leads to significantly

increased urine production. The diuretic effect produces a feeling of losing weight. Moreover,

appetite is reduced when blood sugar levels are high. By taking less insulin, the danger of

hypoglycaemia decreases and the individual can eat less food.


It is noteworthy that underdosing is typically used randomly and more or less unintentionally.

Often, the body feels “fat” and distended. By omitting to inject insulin or by reducing the

insulin doses, one can achieve a diuretic effect and achieve a feeling of weight loss. During

periods of stress or emotional difficulties, individuals may forget unintentionally to take

insulin. The subsequent reduction of weight may be perceived as beneficial or incur positive

feelings, which in turn may reinforce underdosing behaviour.

Individuals who engage in underdosing insulin are often preoccupied with calorie loss

through glucosuria. However, any weight loss incurred following a couple of days of

hyperglycaemia is largely due to dehydration [2]. It is only after several days or weeks of

continual glucosuria that any real weight loss will be noticed as a result of loss of sugar in the


If underdosing of insulin is repeated over a longer period of time, it will lead to considerable

dehydration. The body will produce aldosterone, antidiuretic hormone, and other hormones

which cause the kidneys to produce less urine. When sufficient insulin is eventually supplied,

the glucosuria will diminish, the body will retain fluid and the person will experience a rapid

weight gain. Reduced fluid secretion and the accumulation of fluid will normally continue for

several days, in some cases several weeks. For a person with an eating disorder, this rapid

fluid retention and weight gain is difficult to accept and renewed underdosing causing rapid

dehydration is often the solution. In this way, it appears that the patient is “captured” by the

insulin underdosing method. If the patient manages to maintain a sufficient insulin dose for

one to three weeks, the excess fluid will be excreted and part of the weight gain will be

reversed once again.

In addition to these disturbances of the fluid balance, severe lack of insulin may give rise to

disturbances in the metabolism, so that the breakdown of tissue causes weight loss which is

greater than would be expected from the nutrient supply (catabolism).

Underdosing of insulin does not have its own diagnostic code in the ICD-10, but the condition

occurs clinically as a separate eating disorder and is therefore referred to separately to

distinguish it from the other eating disorders.

Binge eating disorder and diabetes

Binge eating disorder is characterised by 1) ingesting a large quantity of food within a short

time, and 2) a subjective loss of control over food intake. Unlike other forms of overeating

among the overweight, binge eating disorder is characterised by distinct episodes with

significant loss of control over food intake during the episode. The amount of food ingested

during the binge episode is defined as significantly larger than most people would eat under

similar circumstances.

Hypoglycaemia may cause episodes of overeating, but it is unclear what role hypoglycaemia

may play in the development of binge eating disorder in diabetes. For many people, the binge

eating episodes occur in connection with stress or negative emotions. Binge eating disorder

often produces considerable weight gain and increased insulin requirement. The overweight

person becomes predisposed to reduced physical activity, with the subsequent increased risk

of cardiovascular disorders and additional weight gain.


In some cases, binge eating disorder is a cause of diabetes [4]. This can occur if a person

without diabetes experiences significant weight gain and increased body fat. As a result of the

overweight or obesity, the effect of the body’s insulin is reduced so that blood sugar increases

to a diabetic level. Regardless of the cause of weight gain, a person who is genetically

disposed towards type 2 diabetes will develop type 2 diabetes in the presence of overweight.

In some regions of the United States, up to 30 percent of children and young people with

diabetes have type 2 diabetes. In Norway, type 2 diabetes among children and young people is

very rare to date. In the years to come, however, Norway may expect more instances of type 2

diabetes attributable to binge eating disorder among young people.

Many people with binge eating disorder and diabetes never discuss their eating disorder with

health care personnel. The shame of not being able to control their food intake appears to be

one of the reasons why many are reluctant to disclose the problem. The attitudes and interests

of health care personnel towards such problems also play an important role. Available

treatment for persons with binge eating disorder is still poorly developed, although some

health personnel in Norway have reported positive treatment outcome.

The patient’s lack of belief in the quality and availability of care for binge eating disorder

may also contribute to the failure to actively seek treatment.

Bulimia nervosa and diabetes

Among individuals without diabetes, bulimia nervosa normally presents as binge eating

episodes marked by a loss of control, followed by subsequent vomiting. Persons with diabetes

may indeed develop a more ‘classic’ presentation of bulimia nervosa. It is often the case,

however, that an individual with diabetes will choose underdosing of insulin as a purging

method to counteract the effects of the binge-eating episodes. Diuretics or laxatives are also

recognized as compensatory methods common in bulimia nervosa. A relatively large

proportion of patients with bulimia nervosa also suffer from alcohol abuse or polysubstance

abuse [1, 5]. Vomiting, laxative abuse, or the use of diuretics often causes disturbances in

fluid and salt balance. The assessment and treatment of bulimia nervosa is discussed in

“Alvorlige spiseforstyrrelser; retningslinjer for behandling i spesialisthelsetjenesten”

(Serious eating disorders; guidelines for treatment in the specialized health services) [1].

Anorexia nervosa and diabetes

The combination of anorexia nervosa and diabetes occurs relatively seldom. However, when a

person with diabetes develops anorexia nervosa, this leads to serious consequences for the

patient, family, and health professionals. In some cases, comorbid anorexia nervosa and

diabetes is also complicated by symptoms of bulimia nervosa or underdosing of insulin. With

emaciation, the liver’s store of glycogen is often depleted, leading to a much reduced

resistance against hypoglycaemia. It appears that a significant number of the fatalities

associated with anorexia nervosa are due to hypoglycaemia-induced cardiac arrhythmia [6-8].

Few studies exist on mortality due to anorexia nervosa and diabetes. It appears that both

hypoglycaemia and hyperglycaemia contribute to the increased mortality rate seen with

anorexia nervosa and type 1 diabetes [9, 10].


Subclinical eating disorder and diabetes

Subclinical eating disorders are characterised by an abnormal relationship towards food and

the body. In a research context, subclinical eating disorders are often detected with the aid of

screening questionnaires. In some cases, subclinical eating disorders may be a forerunner to a

full-syndrome clinical eating disorder, as this category is frequently used for people who meet

some, but not all, of the diagnostic criteria for anorexia nervosa or bulimia nervosa. For

others, the subclinical eating disorder remains stable or spontaneously remits. A Canadian

survey among girls aged 12-19 years demonstrated that approximately 14% of girls with type

1 diabetes had a subclinical eating disorder. In comparison, the prevalence of subclinical

eating disorders among similarly-aged girls without diabetes was 8 percent [11].

Eating disorders and diabetes: a common combination

In a study of 341 American women with type 1 diabetes aged 13-60 years, 31% reported that

they had deliberately omitted to take insulin. Of these women, 8% reported they regularly

engaged in insulin omission. Of women aged 15-30 years, 16% reported that they regularly

omitted insulin. Motivation to lose weight was reported by one-half of women who omitted

insulin. Several studies confirm the high incidence of underdosing of insulin among persons

with type 1 diabetes [12-15].

Among teenage girls with diabetes, 45-80% reported that they occasionally overeat [16].

However, it is likely that only a proportion of these would satisfy the criteria for binge eating

disorder. Several studies conclude that binge eating disorder is more widespread among

persons with diabetes than in the non-diabetic population. It appears that binge eating disorder

is especially frequent among persons with type 2 diabetes. But persons with type 1 diabetes

also appear to have an increased risk of developing binge eating disorder [17, 18].

Due to the high incidence of underdosing of insulin and binge eating disorder, it is estimated

that approximately 10% of young women with type 1 diabetes meet the criteria for a type of

eating disorder [11, 17, 19-21]. It is uncertain whether there is an increased incidence of

anorexia nervosa among diabetes sufferers. Some studies have reported an increased

incidence of bulimia nervosa among individuals with diabetes [16]. Methodological

limitations, such as small sample sizes and low statistical power, preclude our ability to draw

firm conclusions regarding the comorbidity rates of bulimia nervosa and diabetes [22].

In addition to the common practice of underdosing insulin, or having a comorbid diagnosis of

bulimia nervosa or binge eating disorder, approximately 14% of the girls aged 12-19 years

have a subclinical eating disorder (see separate section on subclinical eating disorder on page

10). Among girls in this age group with type 1 diabetes, about 25% are estimated to have a

full-criteria or subclinical eating disorder [11, 15]. It also appears that teenage boys with type

1 diabetes are more prone to develop eating disorders than those of a similar age without

diabetes [23].

No Norwegian data is available to document the prevalence and incidence of eating disorders

among persons with diabetes. A Swedish population-based survey found no cases of ‘classic’

presentations of anorexia or bulimia nervosa among 89 teenage girls with type 1 diabetes.

However, compared with girls of the same age, there was a clearly increased incidence of

overeating and self- induced vomiting [24]. It is assumed that the incidence of eating

disorders among individuals with diabetes in Norway would fall at the same level as in other

Western countries.

Eating disorders and diabetes: age distribution

Little information exists regarding the age distribution of the various eating disorders among

persons who have diabetes. It would appear, however, that the age distribution among persons

with diabetes is approximately the same as in the eating disorder population at-large. Binge

eating disorder appears to be relatively common across all ages. Underdosing of insulin

appears to occur most frequently among teenagers, whilst bulimia nervosa typically appears

around 18-24 years. Anorexia nervosa is rare in comparison to the other eating disorders,

occurring most often at a relatively young age (15-20 years) [1, 25].

Eating disorders and diabetes: complications

Diabetes with comorbid eating disorders leads to greater complications and increased risk of

mortality [15]. Eating disorders are typically associated with poor regulation of blood sugar,

often resulting in hospital admissions [11]. In addition to acute complications, such as

hyperglycaemia and ketoacidosis, the occurrence of hypoglycaemia accompanied by very few

symptoms (hypoglycaemia unawareness) can result in considerable discomfort for these

patients [26]. Some individuals may resort to excessive exercise to compensate for overeating.

If this exercise is irregular and intense, problems may arise in regulating blood sugar. For

some individuals, unnecessarily large doses of insulin are taken to compensate for feelings of

fullness or to “undo” a binge [24]. It appears, however, that the most common problem is

persistently high blood sugar.

This high blood sugar level combined with poor nutritional status is reported to increase risk

of acute neuropathy [27]. During treatment for high blood sugar and an eating disorder, this

can lead to prolonged and intense pain connected with the regeneration of sensory nerves. The

pain may persist over a prolonged period as the blood sugar is lowered, but often recedes if

blood sugar levels are allowed to rise again. Thus, it can be very difficult to motivate patients

to engage in treatment.

Diabetic complications often occur early in patients with diabetes and an eating disorder.

Chronic autonomous and peripheral neuropathy, in particular, can be a significant problem

[27]. Moreover, diabetic retinopathy appears to occur more often than would be expected

from HbA1c among persons with type 1 diabetes and eating disorders [20]. It appears that

insufficient intake of important nutrients has an unfavourable effect on the incidence of

diabetic complications [27, 28]. Even less severe eating disorders may have serious

consequences in persons with type 1 diabetes, as disordered eating can affect the control of

diabetes to a significant degree [11, 29].

Eating disorders may also occur among persons with diabetes without detection in HbA1c. In

some cases this is due to compensatory behaviours, such as using more insulin or excessive

exercising, which increases the risk of hypoglycaemia [24].

Signs of eating disorders and diabetes

Parents, family, and health care personnel should be aware of the following symptoms which

are warning signs of eating disorders [30]:


Signs of deliberate underdosing with insulin:

– high HbA1c

– frequent ketoacidoses

– parents and family are no longer allowed to take part in treatment assessments

– admitting skipping insulin injections to lose weight

Signs of a problematic relationship to eating and body image:

– unusual preoccupation with dieting and/or episodes of overeating

– frequent complaints about weight and shape

– significant dissatisfaction with one’s body

– unusual preoccupation with food intake (e.g., fat, calorie content)

– large carbohydrate intake without simultaneous use of insulin

– avoids measuring weight in the presence of others

– becomes anxious when talking about weighing

Signs of difficulties in the family:

– family conflicts, poor rapport, and lack of structure

– lack of dialogue between parents

– parents’ preoccupation with weight and shape

Other signs:

– frequent refusal to follow advice and prior agreements on diabetes control and treatment

– fluctuating blood sugar or problems with low blood sugar

– poor attendance record at outpatient clinic

– frequent inpatient admissions

– signs of diabetic complications earlier than expected

When an eating disorder is present, it is recommended that the patient be referred to a

competent authority. Ideally, this may include an interdisciplinary team consisting of a

psychologist/psychiatrist, doctor/internist/endocrinologist, nurse, and clinical nutritional

physiologist . In less severe cases, management may be handled by the primary care physician

and nurse, or a specialist outpatient clinic.

Approaching a person with eating disorder and diabetes

In the treatment of eating disorders, one can often utilize a common technique proven to be

useful across disorders. In the following pages, we first describe this general approach. Next,

specific treatment advice is provided with respect to the different types of eating disorders

commonly seen with diabetes.

Clinical experience suggests that it is beneficial to consider the complicated task of regulating

insulin in relation to food intake, physical activity, feelings, and blood sugar values when

contextualizing the development of eating disorders among individuals with type 1 diabetes.

This is particularly important during youth, as young people in early puberty increasingly

aspire to make their own decisions about daily measurements and treatment. Adolescents are

keen to assume responsibility for actions affecting the requirement of insulin. This is part of

the natural process of gaining greater independence normally seen at this age. It is therefore

neither possible nor particularly prudent to attempt to hinder this process. This

recommendation applies even if, from a treatment perspective, it might appear that better

results would be obtained if parents could retain a prolonged influence over management. As

a consequence, adolescents also assume responsibility for insulin assessments with regard to

changes in food intake, activity, and blood sugar fluctuations. Experience shows that this task

is often complex and demanding, rending assessments quite difficult for young people. Their

mastery of this task is often deemed unsatisfactory, and may quickly arouse negative

appraisals by family members and others, including criticisms that they lack motivation

towards treatment. In this way, they may rapidly encounter the problematical situation of

having to choose one of two unfortunate solutions: 1) taking the ‘easy’ approach to blood

sugar regulation by frequently injecting insulin in insufficient amounts, or 2) mastering the

task of regulation by means of a strict way of life, including a very low carbohydrate intake. It

is difficult to predict which of these two choices, or strategies, a young person will choose.

However, it is probable that the choice is influenced by personality factors and prior

experience of decision-making when facing difficult situations. Once a strategy is first

selected, however, it appears to rapidly take hold and be integrated as a personal solution


Active underdosing of insulin as a solution strategy

If a young person fails to fully acknowledge the significance of having diabetes, as evidenced

by irregularly or minimally regulating blood sugar, or only taking one injection of slow-acting

insulin each morning, the emotional benefits can be strong, making this course of action

highly reinforcing and thereby difficult to change. The underdosing of insulin as an

intentional weight loss/control method also occurs among boys, but to a much less extent than

girls. If the young person, through consultations with healthcare personnel, for example,

decides to increase the amount of insulin, the increased insulin supply will almost

immediately result in weight gain. Such weight gain owes to the dehydration stemming from

prolonged insulin deficiency which causes dehydration. Gaining weight is experienced,

especially by young girls, as quite threatening. Once again, active underdosing of insulin may

resume, and will likely be reinforced as the preferred solution strategy.

Food regulation as a solution strategy

Alternatively, should a young person attempt to master regulating blood sugar level via food

choices and lifestyle, a diet comprised of foods low in carbohydrate is often an easy solution.

The secondary benefit of a low-carbohydrate diet is often weight loss, something which leads

young girls in particular to assume an obsessive eating pattern characterized by self-denial

and an ever-increasing need for control. Hence, both strategies of underdosing and food

regulation may result in weight loss, which is subject to social reinforcement and positive

recognition, which may be perceived as rewarding for young girls. It can be argued that the

highly demanding task of blood sugar regulation itself is a potential risk factor for the

development of a complex relationship to food, weight, body image and appearance. This link

may provide a plausible explanation for an increased prevalence of eating disorders among

young girls with diabetes.

Naturally, several other factors may play a role in the development of eating disorders in

diabetes, but clinical experience indicates that the demanding and complex task of blood

sugar regulation often plays an important role for many patients.


Self-determination and recognition

Successful metabolic control as measured by low HbA1c and thinness are both theorized to

partly stem from the a psychosocial desire and need for recognition and self-esteem. All

young people face difficult social situations requiring social exposure and being judged on

physical appearance when entering relationships with others. Teasing and social exclusion

negatively affects many young people, often resulting in feelings of inadequacy. As a result,

adolescents are often motivated to change their weight and appearance, as physical looks are

often considered necessary for social acceptance. Manipulating food, body size, and insulin

are therefore attempts to solve a universal, existential question, i.e., “Am I good enough?”

Although these issues are not traceable or solely linked to having diabetes, the illness provides

a broader context in which young persons with diabetes must operate. In other words,

mastering the task of regulation, administering insulin, and gaining recognition from others

contributes to their choices, actions, and self-image. All people, regardless of age, share some

concerns surrounding social recognition and seek acceptance from others. In youth, which is a

particularly vulnerable and sensitive period in our lives, physical appearance is very

important, especially for young girls. Health care personnel may be viewed as ‘moralists’ or

adults who don’t understand if they trivialize the normal adolescent desire to be thin and

attractive. It is recommended that healthcare personnel accept such desires with

understanding, ideas, and advice, instead of standard phrases such as, “It’s not your

appearance that matters, but what’s on the inside.” Young people, and perhaps all of us, are

concerned about how other people judge us. We must acknowledge this important facet of

human nature and try to help people with diabetes, regardless of age, to achieve the

recognition they need without this adversely affecting their health.

The good helper – the good relation

It is likely that we all have experienced various incidents during childhood in which our

boundaries have been overstepped. Perhaps we have felt misunderstood, rejected, or violated.

Such incidents typically strengthen our resistance to being taken control of—or having others

take responsibility for our personal decisions. In the treatment of diabetes, it is almost

impossible to avoid some degree of outside control and evaluation. Outside intervention is

perceived in different ways by different individuals, based partly on earlier relational

experiences. However, assessments, rules, and restrictions associated with diabetes control

can be experienced as a significant stressor for some individuals. This issue must be addressed

and handled by the helper in a professional relationship. In concrete terms, this means that

healthcare professionals must meet patients with respect and pay recognition to the individual

as a person, regardless of his/her actions. This shift in focus has proven critical for successful

outcome and developing a good therapeutic relationship. In recent years, both clinical

experience and research has demonstrated that by using recognised therapeutic methods, one

can establish the necessary relationship to create a good alliance for treatment [31].

In principle, there are two different approaches which can be used when working with persons

who have eating disorders and diabetes:

1: One can show support, consideration (with permission), advise (with permission), inform

(with permission), and generally make evident and emphasise that the patient should retain



2: One can establish a situation in which one confronts, directs, warns, shows concern

(without permission), advises (without permission), and informs (without permission) the

patient [31].

From experience, communication and treatment discussions based on the first approach

provide the optimal conditions for change and normally create space for the person to

problem-solve, thus independently seeking solutions to her problems. Such an approach more

readily boosts understanding of the patient’s unique history and characteristics. Improved

understanding of the ‘personal and the particular’ creates a good basis for individual

treatment. Additionally, disputes or power struggles are thereby avoided and health

professionals typically better understand the personal experience of the patient [31, 32].

The good tool

In professional care, a good relationship between carer and patient is absolutely vital to the

success of the treatment. If one does not establish a relationship which gives room for candour

and honesty, then technical and medical aids will likely be of limited use. The insulin pump,

for example, may be a good technical aid to prevent a dramatic weight gain after insulin

increases, but this tool is of limited utility when a patient lacks the desire or motivation to

adhere to recommendations. If one has succeeded in establishing a good partnership with the

patient, however, few limitations exist and fewer protests are encountered when it comes to

experimenting with various insulin types, technical aids, or regulation strategies. Young

people are seldom bound to routines or conventional strategies. They are usually open-minded

when attempting new strategies, as long as proceeding within a secure and inclusive


We can ascertain, therefore, that it may be possible to prevent the development of serious

eating disorders among young persons with diabetes if a good therapeutic relationship has

been established. Our recommendation to health care personnel is that they take time for

reflection and consideration upon consultation with a patient. If one perceives that the patient

is not open or willing to establish an honest collaboration, then the patient should be referred

to others who have experience of handling this type of problem. Although many providers

may protest at such a suggestion, recognizing the critical need to help the patient may

encourage acceptance of the occasional need for external referral. In contrast, if a basis for

understanding and collaboration exists, then a good foundation has probably been laid for

making any necessary changes to the established therapeutic relationship.

After securing patient consent, it can be both important and necessary to bring other members

of the family into the treatment. Parents, siblings, spouses, and partners are important even

though a young person may appear very dismissive about these relationships. Practical,

concrete cooperation and agreements surrounding treatment may loosen a rigid and restrictive

pattern of interaction and help strengthen and connect family members.

Our experience has shown that individuals with diabetes who have developed a complex

relationship with food, weight, and appearance may derive great benefit from sharing their

experiences with others facing a similar situation. A combination of individual and groupbased

treatment methods is often an ideal approach to meeting the various needs of the

patient. Group therapy methods are often used extensively when working with young people.

Clinical observations confirm that young people in particular derive substantial benefit from

sharing their experiences in a like-minded group.

The process of change

If a person with an eating disorder and diabetes seeks treatment for the eating disorder,

behaviour change is achieved via a process of change. This process of change typically

proceeds via fixed phases. First, a patient may not recognize the problem, repress the

problem, or generally demonstrate ambivalence to change. In the literature, this phase may be

described as the ‘precontemplation’ phase. In collaboration with the carer, the patient can

eventually acknowledge the problem, weigh the pros/cons of change, realize that a solution is

achievable, and start thinking about potential ways to manage the problem. This may be

called the ‘contemplation’ phase. If one begins active treatment, then one has progressed to

the ‘action’ phase. When the action phase has been successful in producing the desired

results, maintaining behaviour change can be challenging and requires vigilance and attention.

Thus, it is important to define a ‘maintenance’ phase in which strategies are used to prevent

relapse. Such a step- by- step approach is often used in stop-smoking programmes and among

persons who have abuse problems, but is now increasingly used with eating disorders [31-33].

By establishing a good alliance based on equality and respect, the carer and patient can work

together to define problems, discuss problem-solving strategies, to initiate a process of

change. A concrete example of the change process is described in clinical example no. 4 on

page 28.

Stages of change (4 phases):

– Precontemplation phase

– Contemplation phase

– Action phase

– Maintenance phase

Family work and family therapy

It appears that as eating disorder symptomology progressively worsens, the symptoms

themselves integrate into the family dynamic, resulting in a communication pattern in which

open dialogue is limited. Similar to carers who may ultimately resort to confrontations,

threats, and persuasion to convince children or young people to eat or to take the necessary

insulin, parents may feel increasingly powerless and similarly resort to these methods in an

attempt to help their nearest and dearest. However, this soon leads to a power struggle in

which communication eventually breaks down altogether.

Family therapy therefore occupies a central role in the treatment of the various eating

disorders. In the case of anorexia patients who are under 18 years with a brief duration of

illness, family therapy has a documented positive effect [34, 35]. Although the effectiveness

of family therapy for bulimia nervosa has received less support, clinical experience and

individual case studies provide some evidence for its utility among patients with bulimia

nervosa [1].

In recent times, the family has increasingly been incorporated as a resource when working

with young adults. Lask and Bryant-Waugh have emphasized the benefits of parent

participation in the treatment of their children, demonstrating that their involvement in

treatment improves outcome [36].

Of note, a distinction is typically made between family work and family therapy. In ‘family

work’, the carer supports the parents in their roles and responsibilities. If this is not sufficient

for treatment progress and the family dynamic remains conflictual and rigid, family therapy is

the preferred route. This method may also be necessary if the patient has developed another

serious mental illness in addition to an eating disorder.

In family therapy, the main focus is on the meaning and significance of the individual’s

interactions with his/her environment, plus the patient’s perceptions of the environment and

their management of different situations. From this perspective, the carer is able to initiate a

dialogue with those involved, working on motivation from the position of the individual.

More recent research and clinical experience indicates that the ability of the family and

patient’s network to give control and responsibility to the patient, while providing support for

the patient’s development and health, is vital to a positive outcome [1, 34-36].

Treatment of underdosing of insulin

As noted earlier, underdosing of insulin results in several consequences. High blood sugar

leads to sugar in the urine and thereby, increased secretion of fluids. This, in turn, leads to a

rapid weight loss. The appetite is also reduced, so that the person is able to eat less. With

severe insulin deficiency, the metabolism will also be disrupted, bringing about a weight loss

which is greater than would be expected from the nutrient supply. Even though the original

motivation for underdosing insulin may have not been weight loss or weight maintenance,

underdosing will often quickly be reinforced as an effective dieting method.

High HbA1c values are the simplest and first indication that too little insulin is being

supplied. If the patient-provider relationship is good, then this issue may be frankly and

openly discussed. Both the desire to control food choices and the desire to reduce weight are

natural and normally not problematic. What is unfortunate, and often the focus of treatment, is

the reliance on underdosing insulin as a method to achieve weight loss.

If the underdosing of insulin has continued over time, increasing the supply of insulin will

often lead to substantial weight gain due to initial fluid retention. As a consequence of weight

gain, patients may strongly reject larger insulin doses. This is a critical phase of treatment and

health care personnel must display a great deal of empathy with the difficulties associated

with weight gain. Clinical experience shows that many will require very close follow up

(hospital admission) with a gradual increase of insulin over a long time period. Connecting an

insulin pump has often proven a good technical aid in such a turnaround phase. The one(s) in

the care team who have established the best contact with the patient should take the chief

responsibility for the progress of treatment.

If the patient is made aware that a significant increase in fluid retention will result from

supplying sufficient insulin, this may ease the decision-making process and yield an

agreement on the practicalities of how the insulin treatment should be adjusted. After several

days or weeks, the excess fluid will be excreted once again. But the patient should be made

aware that part of the weight gain will remain. This is because the normal bodily fluid content

produces a higher body weight than the dehydrated condition caused by the underdosing of

insulin. Focusing on the fact that the underdosing of insulin is primarily a fluid regulatory

phenomenon and gives little real weight loss should help with motivation in adjusting the

insulin doses. Substantial catabolism with real associated weight loss occurs only with

pronounced and persistent insulin deficiency. If the patient argues that the underdosing causes

a substantial lessening of appetite, one should discuss whether other methods are available to

bolster appetite control; see section on dietary guidelines in prevention and treatment, page


Using the motivational work described in the section “Approaching a person with eating

disorder and diabetes,” professionals can assist patients in developing solution strategies to

reduce and eventually discontinue underdosing of insulin.

Treatment of binge eating disorder and diabetes

Although binge eating disorder is widespread among diabetic populations as well as the

population-at-large, treatments targeting binge eating disorder are not yet widely available in

Norway. A common clinical perspective characterizes binge eating as a form of emotional

eating, in which food is used for comfort and to manage negative emotions, such as

loneliness. Attempts to increase control over binge eating will therefore have little effect if

treatment does not address triggers for emotional eating. Psychological and therapeutic work

are necessary in many cases to ensure lasting change.

In addition to complicating the regulation of blood sugar in type 1 diabetes, binge eating

disorder can contribute to overweight and obesity, such that a person initially without diabetes

may develop type 2 diabetes. In some cases, professional help may improve or cure the

patient’s type 2 diabetes by treating the binge eating disorder which may contribute to the

development of obesity or overweight.

Numerous medical and psychological complications are associated with obesity. For example,

stress injuries to the skeletal-muscular system and depression are commonly reported among

obese individuals. Addressing comorbid conditions may be a key factor in treatment. For

example, reducing depression may facilitate the regulation of blood sugar, while

simultaneously improving motivation to minimise binge eating.

Treatment of bulimia nervosa and diabetes

In approaching a patient with diabetes and bulimia nervosa, one should follow the general

guidelines described above. When a patient presents with ‘classic’ bulimia nervosa and

diabetes, treatment should follow normal guidelines for bulimia nervosa. Treatment

approaches are described in the treatment guidelines from the Norwegian Board of Health:

Alvorlige spiseforstyrrelser; retningslinjer for behandling i spesialisthelsetjenesten” (Serious

eating disorders; guidelines for treatment in the specialist health services). Evidence-based

treatments for bulimia nervosa include cognitive-behavioral therapy, interpersonal therapy,

and motivational-based therapies, but other forms of psychotherapy may be considered. In

many cases, drug treatment with selective serotonin reuptake inhibitors (SSRI) in combination

with psychotherapy can produce a better effect than psychotherapy alone. A close follow up

and intensive treatment appear to improve the eating disorder and thereby yield significantly

lower HbA1c [37].

In both bulimia nervosa and diabetes, vomiting and underdosing of insulin are commonlyused

purgative or weight-loss methods. Additionally, their simultaneous or alternating

occurrence is not uncommon. A multi-disciplinary approach to treatment is often necessary to

manage the disorder. However, it remains important that the professional with the best

alliance with the patient assume primary responsibility for monitoring treatment progress.

If a patient has bulimia nervosa, the total daily dose of insulin should be adjusted to minimize

the danger of hypoglycaemia, while simultaneously avoiding underdosing with insulin. In

practice, this typically involves accepting a moderately raised HbA1c until the eating disorder

symptoms are under better control.

In some cases, episodes of binge eating are triggered by hypoglycaemia. Should this occur, it

is important to discuss how future hypoglycaemia can be avoided and how to best manage the

hypoglycaemia without triggering a binge eating episode. Many patients are familiar with the

specific types of foods which can easily trigger binge eating episodes. This knowledge and

awareness should be discussed when deciding what types of “hypoglycaemia food” to

consume. Simplifying the insulin treatment to two doses of slow-acting insulin a day may

result in less hypoglycaemia. For others, hypoglycaemia can be avoided by using multiinjection

treatment or the insulin pump. It is important to tailor the choice of insulin regime to

each individual.

Treatment of anorexia nervosa and diabetes

If the patient’s general condition permits, the treatment approach for an individual with both

diabetes and anorexia nervosa should generally follow the main guidelines described above.

The patient’s anorexia nervosa should be treated according to the normal guidelines which are

described in the treatment guidelines from the Norwegian Board of Health: ”Alvorlige

spiseforstyrrelser; retningslinjer for behandling i spesialisthelsetjenesten” (Serious eating

disorders; guidelines for treatment in the specialist health service). Treatment for anorexia

nervosa is typically provided on an individual basis, but group treatment and family therapy

are also effective ways of organising treatment. No studies exist to show that

pharmacotherapy provides additional benefits in the treatment of anorexia nervosa. Research

suggests that SSRI administered at the conclusion of treatment may help minimise the risk of

relapse [1].

If the patient underdoses insulin to control weight, the treatment approach described in the

section on underdosing of insulin should be followed. Considerable resources may be required

to gain control of the insulin treatment in the case of an emaciated person with anorexia

nervosa and underdosing of insulin. In some cases, a long-term hospital stay and close followup

on an outpatient basis is necessary.

The liver’s store of glycogen is often depleted due to emaciation, which results in a greatly

reduced resistance to hypoglycaemia. Additionally, the extreme weight loss renders the

patient insulin sensitive. Some studies indicate that comorbid anorexia nervosa and type 1

diabetes increases risk of hypoglycaemia unawareness and hypoglycaemia-associated

mortality [9, 10].

Fluctuating blood sugar and constant decision-making on blood sugar measurement often

complicates the treatment of anorexia nervosa. As with bulimia nervosa, it may be prudent to

simplify the insulin treatment to two doses of slow-acting insulin a day. In anorexia nervosa,


the need for insulin will often be small due to insulin sensitivity. Adjusting the insulin doses

to pre-empt potential danger of hypoglycaemia while simultaneously avoiding underdosing of

insulin is a challenging task. Typically, this involves accepting a moderately raised HbA1c

until the eating disorder symptoms are under better control. As with bulimia nervosa,

management of patients with comorbid anorexia nervosa and diabetes involves tailoring the

insulin treatment to the individual patient. Some cases may require alternate forms of

treatment, such as multi-injection treatment.

Prevention of eating disorders in diabetes

To date, little is known regarding the etiology of eating disorders among individuals with

diabetes, precluding our ability to develop specific prevention strategies. Some have argued

that merely having diabetes or undergoing diabetes treatment may predispose some

individuals to the development of eating disorders. In this regard, several explanatory

hypotheses have been suggested: strict insulin and mealtime regime, focus on food, a

demanding day- to- day life, mothers’ weight-loss practices, or the tendency towards

overweight among girls at puberty. However, no studies have been conducted which have

conclusively identified the causes of eating disorders among persons with diabetes. A dearth

of knowledge exists on the prevention of eating disorders, although a growing body of

literature is developing on risk and protective factors of eating disorders. Regarding type of

treatment, no studies exist which document whether a specific treatment for diabetes might

reduce the risk of developing eating disorders.

Despite the scare empirical base, our study group has drawn upon expert opinion and clinical

experience to provide some recommendations on how eating disorders might be prevented

among persons with type 1 diabetes.

Overweight and focusing on weight

Weight gain in teenagers

A rapid increase in the prevalence of overweight and obesity has been repeatedly

demonstrated among young people. This effect is observed in diabetic populations as well as

the population-at-large. Girls aged 15-19 years in particular are found to reduce their level of

physical activity while body weight steadily increases. This phenomenon may contribute to

the general focus on body shape and weight in this age group. Teenage girls with type 1

diabetes typically gain significantly more weight than their friends of the same age. A study

among Swedish teenage girls found that the girls with type 1 diabetes were almost 7 kg

heavier than their peers [24]. The reason for this overweight is unknown, but several factors

may be involved. There are probably many reasons why teenage girls with diabetes have a

greater weight gain than their friends without diabetes. Freedom from parents will often lead

to a more irregular lifestyle which yields greater fluctuations in blood sugar, with increased

risk of hypoglycaemia. Many choose to snack in order to avoid hypoglycaemia. Both

hypoglycaemia and hyperinsulinism have a stimulating effect on the appetite. A vicious circle

of overweight, weakened self image, and negative body image can thereby lead to eating

disorders resulting in even greater blood sugar fluctuations.

An American study demonstrated that preoccupation with weight and body shape is common

before the start of puberty. One out of six participants reported at least one of the following

symptoms: dieting, binge eating disorder, insulin omission, or excessive exercise for the

purpose of weight control [30].

It may appear that a significant preoccupation on weight may contribute to the development

of eating disorders. Several studies in sports environments have found a high incidence of

anorexia nervosa in sports that idealise low weight and appearance (i.e., ballet, gymnastics,

and rhythmic gymnastics). It would also appear that attempts at dieting predisposes some

individuals to the development of bulimia nervosa and binge eating disorder. In type 1

diabetes, many young persons will quickly discover that high blood sugar leads to increased

urine production and weight loss. It may be difficult to motivate patients not to diet via

underdosing of insulin when weight gain occurs. Many overweight persons also have

significant levels of depression which may affect diabetes control.


In some outpatient departments, it is routine practice to weigh patients with diabetes. By

determining height and weight, for example, healthcare providers can track children’s growth

to ensure they are experiencing normal growth and development. Among adults, weight gain

can explain an increased insulin requirement. Routine weighing may, however, be perceived

as placing an unreasonable amount of attention upon weight. This vigilance may therefore

contribute to the development of an unhealthy relationship with body weight/shape and

eating. Many teenagers report they perceive weighing as stressful. In particular, individuals

with an eating disorder or a strained relationship towards food (sub-clinical eating disorder)

often find weighing to be difficult and may skip appointments in order to avoid being

weighed. We recommend that weighing young persons with type 1 diabetes be carried out

only if there are clear medical indications and not as a routine part of all outpatient


Normally no medical grounds for recommending weight reduction

Most young people are under considerable pressure to be thin. If a teenager who is moderately

overweight expresses a desire lose weight, it is recommended that health professionals explain

that no medical grounds exist for losing weight. Increased insulin requirements due to

increased insulin resistance connected with weight gain does not provide a basis for

prescribing weight loss. We have no reason to believe that increased insulin doses incur

harmful effects by themselves. Moreover, young persons often engage in weight loss

behaviours which yield only short-term effects, sometimes with additional weight gain as the

ultimate result. It would appear that dieting regimes cause problems with the regulation of

hunger and satiety, thereby increasing the risk of overeating, which in turn increases the risk

of rapid weight gain.

When are there medical grounds for weight reduction?

In the case of serious overweight (BMI over 30), medical grounds exist for recommending

weight loss. Additionally, a carer should be aware of the possibility that a young person with

diabetes may be motivated by a strong desire to lose weight. This motivation may lead to

weight loss attempts despite the existence of medical grounds. Thus, it may be prudent to

encourage discussion about weight loss to open a dialogue and provide advice regarding

reasonable weight loss goals and the types of methods which carry little risk of developing

eating disorders.


How to carry out weight reduction

If a collaborative relationship has been established, it should not be problematic to discuss

dietary suggestions and regular physical activity. Dietary guidelines are discussed in a

separate section; see page 20.

One should be careful in recommending physical exercise if there are signs of an eating

disorder or if the individual appears to have a problem with body image or eating. Among

people with an eating disorder, exercise may be a compensatory behaviour, i.e., excessive or

pathological exercise. In these cases, a reduction in physical activity may therefore be a

critical component of treatment for the eating disorder. Among others, however, physical

activity may have a positive effect on the eating disorder itself [38]. Physical activity should

be a topic of discussion when treating a person with diabetes. In children and young persons,

physical activity will normally be a natural method of weight control. Endurance training as

well as strength training has a positive effect on diabetes. It is important that the type of

exercise be pleasurable and be selected by the individual.

Exercise without dietary restriction will not normally produce a weight loss of more than a

couple of kilos. Unlike weight reduction with energy restriction, weight loss achieved with

increased physical activity appears to be maintained over a longer period [39]. By setting

moderate targets and making use of the weight stabilising effect of physical activity, one may

ideally avoid yo-yo dieting and thereby achieve long-term benefits of the weight-loss regime.

In type 1 diabetes, physical activity will lead to increased insulin sensitivity and the risk of

hypoglycaemia. Insulin sensitivity will remain increased for almost 24 hours following a

single exercise session. Therefore, if one exercises in the afternoon, it is insufficient to only

ensure that blood sugar is good immediately following exercise. Eating a whole-grain bread

sandwich with milk and something similar for supper is recommended, to ingest both fast and

slow-acting carbohydrates in addition to fibre. In this way, stabilisation of the blood sugar is

achieved. It might also be pertinent to reduce evening insulin following an exercise session.

With regular physical activity (at least every other day), one can obtain a stable increase in

insulin sensitivity and reduce unexpected hypoglycaemia.

Among teenagers, it may be necessary to accept a somewhat higher HbA1c to avoid frequent

hypoglycaemia, fluctuating blood sugar, and increased food intake with increased physical


Dietary guidelines in prevention and treatment

Dietary guidelines should help prevent the person from developing a problematic relationship

with food. It is especially important with newly diagnosed diabetes that no foodstuffs are

labelled as ‘forbidden’. A diagnosis of diabetes and the start of insulin treatment should not

lead to a radical change in food and eating habits, including snacking. The general

recommendation to limit amounts of fast-acting sugar (simple carbohydrates) also applies to

persons with diabetes. It can be important with newly-diagnosed diabetes to emphasize that it

is better to consume a little sugar during regular meals rather than to totally eliminate sugar

from the diet. First, the consumption of sugar during mealtimes does not have a negative

effect on the regulation of blood sugar. Second, sugar improves the taste of food, the

individual can live in the same way as others, and the development of a strained relationship

with food is hopefully prevented, especially with sugar and sweetened food.

The new, fast-acting insulin analogues appear to offer a great deal of flexibility in insulin

dosing in relation to food. If a person with diabetes has eaten more than planned, additional

doses of fast-acting insulin analogue will significantly slow the blood sugar increase

following the meal, even though insulin is taken after the meal. Based on current literature,

there are no grounds for believing that increasing insulin doses will have harmful effects.

Diabetic complications are due to the effects of high blood sugar and are not an adverse

consequence of insulin.

Instruction to persons with type 1 diabetes and their immediate family should focus on the

clear connection which exists between food intake, physical activity, and insulin – and that it

is the amount of insulin which should be adjusted.

Unfortunately, many people attempt to use food to regulate blood sugar. When providing

recommendations, one should stress that regulating food intake or physical activity should not

be used to adjust blood sugar. This is because the main objective is to prevent the

development of a problematic relationship with eating and body image. Many people omit a

meal to reduce blood sugar because they perceive food as the cause of their high blood sugar,

or that the body does not need food when blood sugar is high. We recommend that the body’s

need for food should be satisfied and that insulin treatment should be adjusted accordingly.

The fibre content in the diet will be high if whole-grain bread and grain products, pulses,

vegetables (both raw and cooked), and fruit are eaten. Fibre-rich food can also have a

preventive effect in respect to cancer and cardiovascular disorders. Foods of this type will also

increase satiety and help prevent overeating and weight gain. Moreover, the regular intake of

fibre during the course of the day will lead to fewer blood sugar fluctuations. Given a

sufficiently varied diet, vitamin or mineral supplements are not necessary, unless a specific

deficiency is suspected.

There are many good reasons for eating frequently throughout the course of a day. Breakfast,

lunch, dinner, supper, and even another meal eaten during the day (4-5 meals per day)

provides a regular and even supply of energy, which is important for a physically-active

person. This type of eating pattern yields positive effects on the appetite and reduces the

desire for snacking between meals or overeating at mealtimes. It will also help in maintaining

good intestinal function. Last, but not least, large blood sugar fluctuations will be prevented.

If grounds exists for giving advice for weight reduction to a person with diabetes, there may

be reason to discuss the intake of rapidly absorbed sugar and appetite control. It appears that

the intake of too much sugar, both natural and added sugars, especially in liquid form, only

provides a quick feeling of fullness, compared to fats, proteins and more slowly-absorbed

carbohydrates. Should a patient indicate that intake of sugar is high, it is acceptable to

emphasize the appetite-stimulating effect of this type of intake, even if blood sugar is well

under control with fast-acting insulin. One should explain that the intake of fibre makes it

easier to control hunger.

With bulimia, binge eating high-sugar food such as chocolate or other sweets, may present a

challenge for treatment. As recommended with newly-diagnosed diabetes, taking a ‘middleof-

the-road’ approach may be the best choice. It may be appropriate to incorporate a defined

amount of chocolate or other sweets into individual meals to expose the patient and allow for

mastery (exposure with response prevention). In partnership with the patient, the primary

carer should decide whether or when it is appropriate to introduce food which may trigger

overeating, but often exposing the patient to ‘trigger’ foods will be part of the treatment. With

the correct use of insulin, the intake of sweet foodstuffs will not affect blood sugar and incur

little risk of weight gain. It appears that the consumption of small amounts of sweets can

improve self-efficacy and help develop a more secure relationship to food and one’s own

eating habits.

If a person with diabetes has developed an eating disorder or shows signs of developing such

a disorder, one should stress the importance of a varied diet (whole-grain bread, milk and

cheese, potatoes/pasta/rice, meat, fish, eggs, fruit, vegetables, pulses, oils). A sufficient and

varied diet appears to help improve physical and mental strength, so that the patient is ready

to tackle the eating disorder.

How to organise available treatment for diabetes so that those who have an eating

disorder get help?

In diabetes control, questions are regularly raised surrounding insulin, hypoglycaemia,

physical activity, and food. In this context, it is relevant to enhance awareness and discuss

issues regarding our patients’ relationships with food, body image, and self-esteem. “Many

people with diabetes get stressed about eating and food – do you have any problems like

that?” In some cases it may be relevant to explore these issues further with more detailed

questions, such as “How do you feel about your body? Are you happy with it the way it is or

is there something you wish you could change?” or “Does your weight have any effect on the

way you feel?” [40]. With a careful and respectful approach, we can clarify whether the

patient has an eating disorder or may be at-risk for developing an eating disorder

The outpatient departments should be organised to accommodate our patients’ questions and

concerns, so they feel comfortable raising issues involving eating, body image, and food. It

should also be possible to arrange a new appointment relatively quickly if an eating disorder

is reported. It is desirable to have competence in eating disorders available at district

psychiatric outpatient departments or in private psychology practices so that healthcare

personnel working with diabetes can establish a collaboration with personnel who have

sufficient knowledge of eating disorders.

In some cases, it may be necessary to establish multi-disciplinary treatment for a person with

a serious eating disorder and diabetes, so that professionals with different qualifications can

collaborate in helping a patient to tackle both the eating disorder and diabetes.



Eating disorders are common among individuals with diabetes. Even less serious eating

disorders may lead to significant problems with blood sugar regulation, resulting in an

increased risk of complications. Professionals responsible for treating individuals with

diabetes should be aware of how to approach an individual with a potential eating disorder. It

is also recommended that such healthcare professionals be familiar with common signs and

the various risk factors contributing to the development of eating disorders.

Simple, established methods for the treatment of eating disorders are likely the preferred

choice of treatment among persons with diabetes and an eating disorder. Such methods have a

documented effect among eating disorder populations in general. As less severe cases of

eating disorders show some improvement with the aid of simple motivational methods, carers

are recommended to use motivational therapy approaches. The treatment of severe eating

disorders and diabetes, however, often requires special competence, and serious cases should

be treated at the regional specialist units for eating disorders or by other professionals with

specialized training.

Research is recommended to clarify whether the prevalence of eating disorders among

individuals with diabetes is similar in Norway compared to other western countries.

Additionally, controlled studies should be conducted to determine whether methods proven

effective for treating eating disorders in general can be successfully extended to individuals

with comorbid eating disorders and diabetes.

Outpatient departments which provide treatment for diabetes should be organised to offer the

opportunity to discuss issues surrounding eating and body image concerns. In this way,

individuals with diabetes who suffer from an eating disorder may be recognized earlier and

receive help in an efficient manner.