Eating disorders are a significant health problem for many people with Type 1 diabetes, especially among adolescents.

In Type 1 diabetes, the pancreas cannot produce insulin because the cells that manufacture insulin have been destroyed by the body’s own immune system. This insulin must be replaced in order for the body to absorb glucose from food; therefore people with Type 1 diabetes need to administer insulin daily. Managing Type 1 diabetes is a complex balancing act between different pharmacological insulin regimes and support from a diabetes health care team.

A healthy eating plan is a central part of managing Type 1 diabetes, alongside insulin injections or a pump, and a program of physical activity. This means that a person with diabetes will have to focus on their food intake over a long period of time, which can sometimes lead to a problematic relationship with food and eating.

Who is at risk?

Anyone living with diabetes can be at risk of developing an eating disorder; however, research suggests that adolescent and young adult women are most at risk. This may be due to the particular challenges that come with this period in their lives.

For example, during adolescence, factors such as school, peer pressure and body image concerns can lead to significant stress. In addition, developmental and hormonal changes can have an impact on blood sugar control, leading to difficulties in diabetes management.

Young adulthood is a similarly challenging time. Schedules often become busier, there are increasing work pressures, new friendships and serious relationships are formed. This is also a time that people begin to create their own identity.

Risk factors

As well as individual, family and social stresses that can contribute to eating disorders there are additional risk factors for people with diabetes. Some parts of the management and living with Type 1 diabetes that may increase the risk of developing an eating disorder are:

• As part of diabetes management, a person will have to focus on their food intake over a long period of time, which can sometimes lead to a problematic relationship with food and eating.
• Individuals also often experience acute weight gain with the initiation of treatment or improvement in blood glucose control, which can be very distressing.
• Frequent hypoglycaemia (low blood glucose levels) needs to be treated by eating extra sugar and carbohydrates. This extra food can sometimes cause weight gain or trigger bulimic behaviours.
• ‘Insulin-purging’, which is the restriction or omission of insulin to induce weight-loss by ‘purging’ wanted calories.
• Feelings of depression, guilt and/or anxiety can be increased by some aspects of diabetes, such as the constant monitoring of blood glucose levels and worrying about the long-term complications of diabetes.
• Adherence to routine meals, snacks and ongoing diabetes management can be disruptive and place limitations on an individual’s life which can cause frustration.

Are eating disorders worse for a person with diabetes?

Eating disorders can create extra risks for a person with diabetes. They are particularly concerning in combination with Type 1 diabetes, as they lead to poor glucose control, and increased risk of secondary diabetes complications such as diabetic eye, nerve and kidney damage.

Persistent high blood glucose levels can also lead to weight loss. Diabetic ketoacidosis (DKA), a potentially life-threatening condition, can potentially be precipitated by the high blood glucose levels caused by missing or decreasing insulin doses so that glucose and calories are lost through the urine. Episodes of severe low blood sugar (hypos) can occur if food is restricted or purged (vomited), which makes it difficult for the appropriate insulin dose to be taken.

Warning signs

Specific warning signs of an eating disorder in a person who has diabetes include:

• Extreme fluctuations in blood glucose levels.
• Frequent high or low blood glucose levels and/or diabetic ketoacidosis (DKA), possibly resulting in hospital admission.
• Consistent extremely high HbA1c (a blood test which measures the overall blood glucose levels over the last two to three months).
• Missing insulin doses, or changing doses significantly or frequently.
• Extreme fluctuations in weight.
• Fear of hypoglycaemia.
• Fear or distress at injecting, or insistence at injecting in private.
• Frequent requests to change meal plans.
• Non-diabetic eating disorder symptoms.

What can I do to help my child, partner or friend who has Type 1 diabetes?

If someone you know with Type 1 diabetes is showing signs of an eating disorder, you are encouraged to help them. Early intervention is important and can make all the difference in recovery. It is important to seek help from a team of health professionals that understand both Type 1 diabetes and eating disorders. That may include an endocrinologist, general practitioner, diabetes educator, dietitian, social worker, psychologist or psychiatrist.

Studies show that a high percentage of people with an eating disorder will experience increased levels of anxiety and depression. It isn’t clear if depression and anxiety are the result of an eating disorder or a risk factor in the development of one — the truth could be a mixture of the two.

Eating disorders, anxiety and depression have common risk factors. Thankfully, they are all conditions that can be treated effectively with the help of health professionals.

Depression

People with depression find it hard to function every day and may be reluctant to participate in activities they once enjoyed. It is very common for people with an eating disorder to experience a level of depression at some time or another.

Depression is one of the most common of all mental health problems with an estimated one in five people experiencing it at some stage of their lives. However, it can be treated effectively.

Signs and symptoms

Common behaviour associated with depression includes some or all of the following symptoms for more than two weeks:

• Moodiness that is out of character
• Increased irritability and frustration
• Finding it hard to take minor personal criticisms
• Spending less time with friends and family
• Loss of interest in food, sex, exercise or other pleasurable activities
• Being awake throughout the night
• Increased alcohol and drug use
• Staying home from work or school
• Increased physical health complaints like fatigue or pain
• Being reckless or taking unnecessary risks (e.g. driving fast or dangerously)
• Slowing down of thoughts and actions

Anxiety

An anxiety disorder involves more than just feeling stressed — it’s a serious mental illness. People with anxiety disorders find it hard to function every day. Anxiety disorders are the most common mental disorders in Australia. Nearly one in 10 people will experience some type of anxiety disorder in any one year, and one in four people will experience it throughout their lives. Women are more likely than men to report anxiety disorders (12% compared with 7.1%) and affective disorders (7.4% compared with 4.2%).

What causes anxiety disorders?

Combinations of factors are believed to trigger anxiety disorders and may include:

• A family history of mental health problems
• Stressful life events
• Ongoing physical illness
• Personality factors

Types of anxiety disorders

There are many types of anxiety disorders with a range of signs and symptoms.

Generalised anxiety disorder (GAD) – involves feeling anxious, restless and/or worried on most days over a long period of time.

Obsessive compulsive disorder (OCD) – occurs when a person has ongoing unwanted and intrusive thoughts and fears that cause anxiety, often called obsessions. These obsessions make them feel they need to carry out certain rituals in order to feel less anxious, and these are known as compulsions.

Phobias – can cause a person to feel very fearful about particular objects or situations.

Post-traumatic stress disorder (PTSD) – involves experiencing bursts of anxiety that occur after a person has a major emotional shock following a stressful event, i.e. a trauma, such as experiencing or witnessing a scenario involving death, injury, torture or abuse.

Panic disorder – involves having panic attacks frequently. Panic attacks are intense feelings of anxiety that seem like they cannot be brought under control.

Autism Spectrum Disorder (ASD) is a developmental condition that affects the way individuals interact and communicate with others. The word “spectrum” reflects that there are differing degrees by which people are affected — some may require ongoing support and care; others are able to live independent lives.

 Several studies have confirmed a link between eating disorders and autism spectrum disorders.

This is because people on the autism spectrum usually have repetitive or restricted behaviours, which overlap with behaviours seen in eating disorders.

They may have highly selective eating requirements or be particularly sensitive to the textures, look, smell or sound of foods. In some cases, people with ASD eat or chew non-food items such as paper, soap or pebbles — this is known as pica. The social aspects of eating (such as sitting at a table with others, waiting until others are finished) can also be challenging. There may also be physical difficulties such as oral problems (difficulties chewing or swallowing) or gastrointestinal problems, which make eating a non-pleasurable experience.

Some studies have shown that people with ASD may have a lower body weight than expected due to factors such as eating difficulties and general hyperactivity. Several behavioural patterns and personality traits appear to be common to people with both anorexia and ASD. A 2013 study by Professor Simon Baron-Cohen found that the girls with ASD had lower empathy and a greater tendency to systemise (create and follow rules) than other people, as did the girls with anorexia. Both groups showed:

• A strong interest in details and systems
• A tendency to focus on themselves
• Inflexible behaviours and attitudes

The majority of people diagnosed with ASD are male, while the majority of people diagnosed with anorexia are female. It has been suggested in fact that some girls with ASD are being misdiagnosed or overlooked because they present to their doctors the symptoms of anorexia.

“Traditionally, anorexia has been viewed purely as an eating disorder. This is quite reasonable, since the girl’s dangerously low weight, and their risk of malnutrition or even death has to be the highest priority. But this new research is suggesting that underlying the surface behaviour, the mind of a person with anorexia may share a lot with the mind of a person with autism. In both conditions, there is a strong interest in systems. In girls with anorexia, they have latched onto a system that concerns body weight, shape, and food intake.”

– Professor Simon Baron-Cohen.