Devon quickly pulls her sleeve down and adjusts her baggy tracksuit as if to hide her entire body. She looks anxious and ill, and says she has been dieting and running every day. Devon does not want to be weighed, complaining that she is too heavy. In spite of the obvious weight loss, her blood glucose levels are high. I suspect that Devon is developing an eating disorder.

For someone Devon’s age, a diagnosis of diabetes has a huge effect on both lifestyle and general well-being. Developing an eating disorder while coping with diabetes can cause very serious problems.

Diabetes and eating disorders

Unfortunately, the treatment of the first disease (diabetes) may lead to another (an eating disorder). Someone with an eating disorder eats in a way that threatens physical health. Extreme emotions and behaviour often surround weight and food issues.

To manage diabetes, food and insulin doses must be carefully balanced. Daily exercise is also necessary to keep blood glucose levels and body weight under control. Ironically, this aspect of diabetes care has a similar focus to the physical and emotional development of an eating disorder.

Everyone supporting or caring for a young person with diabetes should be aware there is an associated, increased risk of a serious eating disorder.

Cultural influences

Our society encourages careful control of how much we eat and weigh with an emphasis on avoiding obesity. Particularly for girls, being slim is seen as the same as being beautiful. Television advertising, movies and magazines emphasize the need to diet. Young people feel pressure to be slim as a way of being happy and admired.

Studies done in North America and Europe show that many teens and young adults are overly focused on body weight, body image, food and dieting. As a result, more young people are developing eating disorders.

What does an eating disorder look like?

People affected by an eating disorder, especially teens, tend to be secretive. Baggy clothes hide rapid weight loss and a body thought to be ‘fat.’ Since they don’t usually recognize they have a problem, they rarely seek medical advice. This makes early diagnosis difficult.

The study of eating disorders is fairly new. We do know that three main types of eating disorders exist. In anorexia nervosa, a person eats so little or is so afraid of eating that the body starves. In bulimia nervosa, overeating is followed by purging - vomiting or using laxatives to prevent digestion of food. Both conditions can lead to excess weight loss and chemical changes in the brain that threaten life.

Binge eating disorder involves losing control and either eating too much at once or eating too often. Those with this disorder make no effort to prevent weight gain by exercising or purging.

What are the differences and similarities between diabetes and eating disorders?

Both diabetes and eating disorders place demands on the young person to manage the type and amount of food eaten. Both conditions encourage thinking that some foods as 'good for me' or 'safe,' and that others as 'bad for me' or 'dangerous.' A young person with diabetes can usually rationalize that the demands and expectations about the amount and type of food eaten are logical and necessary for them to control their diabetes and lead a healthy, active life. The emotions of a young person with an eating disorder may distort their logic and control over these external demands. These changed thought processes lead to illogical, uncontrolled behaviour regarding 'bad' or 'dangerous' foods, and are opposite to a healthy life and survival.

Control and anxiety can also be issues. People with diabetes often feel anxious and out of control if their blood glucose levels are not well-managed and change unpredictably. Those with anorexia or bulimia may feel similar emotions if their body weight changes. However, for the young person with diabetes, the anxiety can lessen or go away once the blood glucose levels return to normal and they feel they are in control of their diabetes. For those with an eating disorder, a constant and illogical anxiety about body weight and body image persists.

Adolescents with diabetes often think that their parents are overly protective and controlling. Young people with an eating disorder frequently describe their parents in the same way. In both cases, the family's involvement can be seen by the adolescent as a problem instead of a support. Although it is normal for adolescents to struggle with a need for independence, with many finding their parents over-protective or controlling, it is much more difficult for the parents of a teen with a chronic illness such as diabetes to find a satisfactory balance between letting go and remaining supportive. Sometimes a parent's genuine fear for their teen's health and safety can be misinterpreted by the young person as nagging or controlling.

Misusing insulin to lose weight

Young people who take insulin to control diabetes can also misuse it in order to lose weight. If the daily insulin dose is reduced, blood glucose levels will rise. Without enough insulin, glucose in the blood cannot be absorbed into muscles and cells to be used for energy and growth. Instead, the glucose is released through the kidneys in urine, so that valuable nutrition is lost. The young person will lose weight rapidly.

This biochemical process can be dangerous, possibly fatal. It can also trigger a serious eating disorder. Even if young people are made aware of the danger of reducing insulin, they may be reluctant or unable to stop. The strong desire to be 'thin' and to achieve society’s expectations may push them to continue misusing insulin.

What are the results?

Complications of diabetes combined with an eating disorder can be very serious. Once a person begins to starve, stuff, binge or purge food, the behaviour can alter brain chemistry and function. This can make the condition worse and lead to potentially fatal complications such as:

poor circulation
damage to the stomach and intestines
disruption of fluid and mineral balance
weakening of the immune (defence) system
kidney failure
blindness
nerve damage
liver damage
damage to the heart and heart failure.

Without immediate treatment, up to 20 per cent of young people with both diabetes and an eating disorder will die.

Watch for the signs

Young people with eating disorders are always very focused on weight, food and diet. Unfortunately, those with diabetes must continue to focus on these issues in order to manage the disease. Thanks to the necessary daily management, it is easy to use diabetes as a mask for anorexia or bulimia. Parents often find it difficult to know what is normal behaviour related to diabetes, and what is becoming an emotional and harmful problem.

Certain signs indicate that a serious problem is developing. The person may:

have severe and continual weight loss
dip below the normal growth curve for height and weight seen on a growth chart
change eating behaviours
show disgust for former food favourites, such as hamburgers, pizza, desserts
eat only fat-free foods or salads
refuse to eat with the family
run to the bathroom after eating (to get rid of food)
exercise continually
express fear of weight gain
wear baggy clothes that cover the entire body
have poor self-image or low self-esteem
have frequent high blood glucose levels.
develop diabetic ketoacidosis (an extremely serious condition that can lead to coma and death) if daily insulin is reduced.

What can a parent do?

It is essential to recognize the early signs. Beginning treatment as soon as possible is the first and biggest step. Usually the young person will deny any problem and refuse treatment. This complicates the path to recovery.
The longer symptoms are missed or ignored, the harder it is to get better. The risk of serious complications also increases.

The first priority is to restore physical health and reverse the harmful effects of starvation. Many months or years of counselling and management may be necessary to address the emotional issues.

Without treatment, up to 20 per cent of these young people will die. With early treatment, up to 60 per cent will recover. Even with treatment, up to 20 per cent relapse and require ongoing support along with psychological and emotional interventions.

Awareness is the best prevention strategy

Unfortunately for young people with diabetes, the physical and emotional factors that help trigger the eating disorder will never go away. Managing diabetes is a commitment that lasts for life. Family, friends and health care providers must remain constantly aware that a problem could develop. Recognizing and reducing potential risks, and identifying early problem signs can help prevent someone like Devon from developing a serious or possibly fatal condition.

Parents have the difficult responsibility of nurturing, protecting and caring for a child with diabetes over the long term. This job can sometimes be overwhelming, particularly during the adolescent years. Although a teen may perceive their parents as over-protective or controlling, they still rely on their family for unconditional love, security and their means of survival. Understanding a young person's need for independence should be balanced with ensuring their safety and well being.

Early diagnosis and treatment is essential for successful treatment. Many resources and supports are available, including the young person's physician, diabetes educator, dietitian, counsellor, or social worker. Contact one of them immediately if you suspect an eating disorder may be developing. School counsellors, community health nurses, school nurses, extended family and the young person's friends could all become supports and advocates.

Eating Disorders A serious risk for young people with diabetes

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