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Eating Disorder

A severe disturbance in eating behavior, such as extreme undereating or overeating. Some studies suggest that eating disorders may be more common in adolescent girls with Type 1 diabetes than in their peers who don’t have diabetes. Eating disorders can wreak havoc on diabetes control.

The three most common eating disorders are anorexia nervosa, bulimia nervosa, and binge-eating disorder. They predominantly affect adolescent girls and young women. Anorexia nervosa afflicts an estimated 0.5% to 3.7% of girls and women over the course of their lifetime. Individuals with anorexia nervosa tend to be intensely worried about gaining weight or becoming overweight, despite the fact that they are extremely underweight. They tend to have distorted perceptions about their own bodies, thinking they are heavier than they actually are, and to deny the seriousness of their low body weight. They may avoid meals, choose only a few types of food and eat them in small quantities, and painstakingly weigh and portion their food. They may use other measures to control their weight, such as exercising compulsively, forcing themselves to vomit, or abusing laxatives, enemas, or diuretics (“water pills”).

Anorexia carries a heavy toll: Girls with the disorder often have delayed onset of their first menstrual period or irregular menstruation, which may impair fertility and is associated with osteoporosis. The rate of death from anorexia is estimated at 0.56% per year of illness (meaning around 5.6% for those who have had anorexia for a decade). Individuals with anorexia nervosa tend to die from such complications as cardiac arrest or electrolyte imbalance, or from suicide.

In someone with Type 1 diabetes, the effects of anorexia nervosa can include poor diabetes control, growth delay, frequent bouts of the life-
threatening condition diabetic ketoacidosis (DKA), early onset of diabetes-related complications, and premature death.

The earlier anorexia nervosa is diagnosed and treated, the better the chances of successful treatment. Often, the first step is to hospitalize the person to restore the weight that was lost through excessive dieting and possibly purging, sometimes with the help of intravenous feeding. After the person begins to gain weight, psychotherapy is started to help improve self-esteem and correct distorted perceptions and behavior patterns. In some cases, certain antidepressant medicines in the class of drugs known as selective serotonin-reuptake inhibitors (SSRIs) may be used, notably fluoxetine (brand name Prozac). However, it is unclear how helpful SSRIs are in treating anorexia.

Bulimia nervosa affects an estimated 1.1% to 4.2% of girls and women at some point in their lives. It is characterized by repeated episodes of uncontrollable binge eating, followed by self-induced vomiting; abuse of laxatives, diuretics, or enemas; fasting; or excessive exercise to prevent weight gain. Like people with anorexia, bulimic individuals are afraid of gaining weight and are intensely dissatisfied with their bodies. Purging behaviors in bulimia can cause many complications. For example, exposure to stomach acids from frequent vomiting can cause a chronically inflamed and sore throat and can wear away at tooth enamel, leading to tooth decay. Laxative abuse can cause intestinal distress and irritation, and diuretic abuse can lead to kidney problems. The purging of fluids also sets the stage for severe dehydration. As one might expect, bulimia can disrupt blood glucose control in people with diabetes, causing repeated episodes of hypoglycemia.

Bulimia is treated with psychotherapy and other types of counseling, and with medication. Counseling is geared toward helping the person establish a regular eating pattern, improve negative attitudes, maintain a healthy exercise routine, and cope with any underlying mood or anxiety disorders. Sometimes SSRIs or other medicines may be helpful, as well.

It is estimated that 2% to 5% of Americans have binge-eating disorder in any given six-month period. Binge-eating disorder is characterized by episodes of uncontrollable over-eating, with no purging behavior. People with binge-eating disorder tend to eat much more rapidly than normal, eat until they feel uncomfortably full, or eat large amounts of food when they’re not feeling hungry. Often they feel shame or guilt about their binges. In people with diabetes, binge eating can be triggered by episodes of hypoglycemia (low blood glucose). Even small binges in people with diabetes can disrupt blood glucose control and lead to negative feelings. People with binge-eating disorder are generally treated with SSRIs and psychotherapy, particularly a type of psychotherapy called cognitive-behavioral therapy.

Some eating disorders are unique to people with diabetes. People with Type 1 diabetes sometimes skip insulin injections or reduce the size of a dose to lose weight or to prevent weight gain. This is sometimes called “diabulimia.” Without sufficient insulin, glucose cannot get into the body’s tissues to be stored as fat. Instead, it builds up in the bloodstream, raising blood glucose levels, and then gets excreted in the urine. According to various studies, between 5% and 39% of young women with diabetes omit or decrease insulin doses for weight loss. This is an extremely dangerous practice, as it can lead to diabetic ketoacidosis (DKA), a serious and life-threatening condition. Frequent periods of high blood glucose also increase the risk of developing diabetes-related complications, sometimes very early in life.

Night-eating syndrome is characterized by heavy snacking (consuming at least one-quarter of the day’s food intake) after the evening meal and/or frequently waking up at night to eat. People with night-eating syndrome also tend to eat foods rich in carbohydrate and fat. Often they wind up eating at night in response to emotional triggers such as anger, sadness, loneliness, or worry. A study published recently in the journal Diabetes Care showed that people with either Type 1 or Type 2 diabetes who have night-eating syndrome tend to be more obese, have higher HbA1c levels (a measure of blood glucose control), and have more diabetes complications than those without night-eating syndrome.

Treatment for night-eating syndrome involves treating underlying mood disorders such as anxiety or depression through psychotherapy and/or medicines such as SSRIs. Psychotherapy involves helping a person find other ways of coping with negative emotions and may include relaxation therapy or cognitive-behavioral therapy.

If you or someone close to you has signs of an eating disorder, discuss your concerns with your health-care team. Eating disorders are serious but treatable medical conditions.

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