Prevalence, diagnosis, and treatment
Preface
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
Director
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
Introduction
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
disorders.
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
urine.
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
strategy.
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
control.
or
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
framework.
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
20.
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,
18
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.
Weighing
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
consultations.
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
activity.
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.
Conclusions
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.
