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PEP Talk

Eating Disorders and Your Teenager   

(Adapted from “When Diabetes Hits Home….the Whole Family’s Guide to Emotional Health” by Wendy Satin Rapaport, LCSW, PsyD)

>>Watch a video message from Dr. Rapaport

Diagnosis of Eating Disorders

With diabetes and eating disorders, there are elevated hemoglobin a1c levels, hypoglycemia from purging or food restriction, and episodes of ketoacidosis. Eating disorders can seriously damage the health of people with diabetes. To treat them successfully may require education, therapy – individual, family and/or group – and antidepressant and anti-anxiety medications. Of course exercise and nutritional counseling are vital.

With the diagnosis of an eating disorder, families may have to wrestle with self-doubt, guilt, blame, resentment, and anger at each other as well as the person with the disorder.

With the help of professionals, families can adjust to new guidelines and structure that his good for the prevention of eating disorders as well. They will need to:

• Balance privacy and separateness
• Allow conflict
• Deemphasize appearance so self-worth is not dependent on weight
• Focus on feelings, not food
• Make mealtimes pleasant
• Stay away from controlling or scolding about food behaviors
• Discuss what situations are uncomfortable (for example, eating out in restaurants)
• Continue to do the things that are satisfying and pleasurable

The most important of these may be focusing on feelings, not food. Diabetes brings up powerful feelings. If you do not have healthy ways to acknowledge and live with those feelings, you are likely to use food as an unhealthy way to cope.
Types of Eating Disorders

Anorexia is characterized by a drive for thinness: pursuing weight loss or, in the case of children, refusing normal weight gain; an exceptional fear of becoming fat, regardless of being very underweight; a disturbed body image; and lack of menstrual periods or loss of sexual interest in males. The person with the disorder restricts food through fasting, dieting and exercising. Mood disturbances are made worse by the state of semi-starvation. Losing weight may initially be an attempt to achieve a sense of control and feel good about oneself. It changes into an obsessional preoccupation with weight and denying oneself food.

Bulimia is when individuals are preoccupied by their weight but have periods of “giving in” to their desire to overeat and then, regretfully, try to take control through purging. The binge-eating periods include an amount much larger than others would eat, sometimes many thousands of calories. During the binges individuals have an out-of-control feeling that they cannot stop eating. The binges are followed by restricting food, or by excessive exercise or various purging methods. The additional danger in diabetes is purging by intentionally omitting or reducing an insulin dose for the purpose of getting rid of the calories…an action that can lead to ketoacidosis and coma. This is more difficult to detect than anorexia because individuals have near normal body weight. They are more aware than people with anorexia that their behaviors are different and unhealthy, and they are more interested in receiving treatment.

Binge eating is a common problem, suggested to affect 20% of people who are obese. Binge eaters are not so concerned with weight loss, and the binges are not followed by the purge cycle found in bulimia. Generally, the individual does three or more of the following: eat rapidly; eat when not hungry; eat until overly full; eat alone because of the shame over the amount; and feel distress over their eating, which leads to feeling depressed and guilty. They do not emphasize weight control, and they gain more weight. Episodes of binge eating usually occurs at least two days a week for more than six months. My colleague Lisa Schwarz’s research showed the association of binge eating with weight dissatisfaction, poor adherence to diabetes care and levels of depression. A mental health professional can help with underlying depression or mood disorders and appropriate medication.

Insulin manipulation is another sort of eating problem (but not a clinical problem). It is the occasional poor usage of food or insulin and a negative preoccupation with one’s body. This affects a significant portion of the population with diabetes. Insulin manipulation is thought to be related to fears of weight gain or concerns with hypoglycemia. Research indicates that 31% of individuals omit insulin at certain times, but 8% do it frequently, risking severe complications.

Prevention is Key

An eating disorder can be a complication of diabetes and can cause other complications. Be conscious, not worried.

Most people with diabetes do not develop eating disorders. The necessary focus on food and weight in diabetes can make you question whether your child has a problem. She (or he) probably does not. However, if your child never thinks she is thin enough, no matter what her weight is, or she deliberately changes her insulin or medication to lose weight, she does have a problem. Letting blood glucose levels run high all the time means that a change in routine or other health status could put her at risk for a life-threatening condition that can lead to coma and death. Certainly, chronic high blood glucose puts her at risk for complications. Seek professional help.

In diabetes, food can become a preoccupying aspect of life, and other people – family and medical team – can be perceived as being overly involved in one's personal habits. The diagnosis can make you and your family feel helpless at first and cause your child to try to bring a sense of control over her life with the use of food. This is the one thing that children and adolescents feel they have control over.

Sometimes professionals or families can miss the diagnosis of eating disorders even as we are complimenting patients on their weight loss, not realizing that they accomplish this at the expense of good diabetes care.

I was concerned about one young girl, and educated the mother about the issue, but the mother was still more focused on how happy she was that her daughter was thin. She told me the secret of her daughter’s success had been in drinking lots of water. Only the third elevated glycosylated hemoglobin test convinced her that the drinking resulted from the thirst of high blood glucose levels. Her own desire to be thin and to have a daughter like her blocked her from acting on what we already knew.

Prevention strategies and speedy discovery are of the utmost importance. Eating disorders are more difficult to treat when they are entrenched as patterns in an individual’s life.

Eating disorders appear as a preoccupation with dieting and thinness. While food (eating it, getting rid of it, or avoiding it), body image, shame, and secrecy appear to be the main issues, the underlying feelings encompass powerless, depression, anxiety, loneliness, anger and all-or-nothing and perfectionist thinking. The disorder finds resolution in the external solution – food, diet, thinness – rather than the internal solution – regulation of emotions.


People with diabetes need to have an unusual focus on food.  Know the signs of an eating disorder, and keep the lines of communication with your teen open.  Prevention is key!

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