It’s a little known fact that young people with diabetes are more at risk of developing an eating disorder. In this special report we look at the issue and how friends and family can help. By Caroline Wood.

It’s something of a hidden problem in the community but people with diabetes are two to three times more likely than the non-diabetes population to have an eating disorder.

People living with type 1 diabetes are most likely to be affected, with young T1D women at most risk. While less common, people with type 2 diabetes can also develop an eating disorder, for example binge eating is more common among T2Ds.

“It’s really important that people get early help,” says Dr Roger Mysliwiec, one of New Zealand’s leading experts in the field of eating disorders.

Dr Mysliwiec is trying to raise awareness about eating disorders and type 1 diabetes in particular because he’s worried that young people aren’t being offered the help they need.

He is calling for more screening and early intervention as treatment is much harder the longer someone has an eating disorder.

“Young people with diabetes can fall through the cracks. On the one hand they may not be getting screened at their diabetes clinic, and on the other their symptoms may not be obvious so they don’t get access to eating disorder services,” he says.

“With diabetes, even if your eating disorder isn’t very severe, if it leads to elevated blood sugars then that is a concern regarding potential complications.

“If it’s severe they should go and see an eating disorder service and make sure they closely collaborate with diabetes treatment.”

The most common eating disorder found in people with diabetes is EDNOS (Eating Disorder Not Otherwise Specified) where someone displays eating behaviours that have a significant impact on their psychological and physical health. Other eating disorders include diabulimia, bulimia, and anorexia, which is less common.

Diabulimia, where a person reduces their insulin in order to reduce their weight, is a particular eating disorder that is only found in people with type 1 diabetes.

“Omitting insulin functions as a kind of purging behaviour, getting rid of calories. By omitting, or taking less, insulin, glucose doesn’t get into the cells and therefore prevents weight gain or even leads to weight loss,” explains Dr Mysliwiec.

“But doing this predisposes the individual to the acute complications of high blood sugar levels and the severe long-term complications of elevated HbA1c.”

Prevalence studies show that eating disorders are two to three times more common in people with diabetes, compared with the non-diabetes population.

For example, one study of 12 to 19 year olds found that 10% of the patients with diabetes had an eating disorder, compared with 4% of the non-diabetic subjects.

And there will be many more people who have problems with eating but their symptoms don’t meet the diagnostic criteria for eating disorders and treatment.

There is thought to be a strong genetic factor predisposing some people to eating disorders. For example, a large genome-wide study showed there was an association between anorexia and diabetes, which could mean a person with this particular gene will have a genetic predisposition to developing anorexia.

Dr Mysliwiec says that once someone has developed an eating disorder it’s a race against time. “I would unfortunately see most patients at the very severe end, which is the ‘bottom of the cliff’ scenario.

“Once the behaviours have become so entrenched and the complications are severe, it’s so much harder to help people, it’s very challenging. The ideal is always early intervention.

“By investing in screening and early support, one can prevent the very high cost to both the individual’s health and to society.”

TIME FOR ACTION

People with diabetes often have a number of risk factors that come together, which mean they are more likely to develop an eating disorder.

Hypoglycaemic (low blood sugar) episodes can lead to disinhibited eating, which over time can lead to regular over-eating of highly palatable foods and unwanted weight gain, increasing the risk for risky weight loss behaviour. The hormone insulin also leads to higher fat building in the body.

Diabetes management also requires a preoccupation with weight, carbohydrate and fat intake. And the onset of diabetes often co-occurs with adolescence with its common concerns about weight and shape.

It’s thought the Waikato Diabetes Service is the only district health board currently screening people with diabetes for eating disorders. When it sent out a questionnaire, more than 20% of respondents reported some kind of eating issue, according to Dr Roger Mysliwiec.

Diabetes NZ’s Chief Executive Heather Verry said: “We are concerned that people with diabetes are more at risk than the general population, with one study showing that one in 10 teenagers with diabetes had an eating disorder. We want to raise awareness of this issue in the community and urge anyone who is worried about a child or friend to seek help from their GP, diabetes clinic, or the DEDA website

“It’s vital that people are diagnosed and treated early. We’d like to see more screening for eating disorders in diabetes clinics nationwide and more publicly funded treatment for people who need it. We echo concerns that this is a hidden problem in our community, that people, particularly young women, are falling through the cracks and suffering in silence.”

Dr Mysliwiec is one of the clinical leaders on a project that aims to find the true number of young Kiwis with diabetes who are also struggling with an eating disorder.

The study will include Waikato, Auckland, Waitemata, and Counties Manukau District Health Boards. It will initially involve screening diabetes patients (male and female) between 15-25 years for six months via a clinical Diabetes Eating Problem Survey. Patients will be asked to fill it in at their regular clinical visit.

It’s hoped the study will provide a stronger rationale to provide funding for routine screening and provision of treatment for eating disorder behaviours in people with type 1 diabetes.

*This article is linked to the story 'Here to Help', which you can read here.

 **This article first appeared in the Autumn 2018 issue of Diabetes Wellness magazine. Subscribe to Diabetes NZ today to receive your copy.