• How many people have both an eating disorder and diabetes?

We are not sure, but the combination is common. Some clinicians think that eating disorders are more common among folks with diabetes than they are in the general population. Research is currently underway to find out if this is so.

• Does diabetes cause anorexia nervosa or bulimia?

No, diabetes does not cause eating disorders, but it can set the stage, physically and emotionally, for their development. Once people develop eating disorders, they can hide them in the overall diabetic constellation. This makes treatment and even diagnosis difficult. In some of these cases the eating disorder has gone undetected for years, sometimes coming to light only when life-altering complications appear.

• What are some of those life-altering complications?

Blindness, kidney disease, impaired circulation, nerve death, and amputation of limbs. Death, of course, is the ultimate life-altering complication.

People who have both diabetes and an eating disorder eat in ways that would make their doctors wince. Many believe that being fat, a perceived immediate threat, is far worse than the consequences noted above which may never happen, or if they do, will happen years down the road. Like Scarlett O’Hara, they will worry tomorrow.

Many of these people superstitiously believe they will escape complications. They are wrong.

• What is the main mechanism that connects diabetes and eating disorders?

People who take insulin to control their diabetes can misuse it to lose weight. If they cut back the required dosage, blood sugar will rise and spill over into the urine. These folks will lose weight, but the biochemical process is particularly dangerous. Reducing insulin causes body tissues to dissolve and be flushed out in urination.

Once diabetics discover that they can manipulate their weight this way, they are reluctant to stop even if they know about potential consequences because weight loss is rewarding in our fat-phobic culture. They decide to maintain the weight loss, and that decision can serve as the trigger for a full-blown eating disorder.

• What are the similarities between diabetes and eating disorders?

Both demand that people pay close attention to body states, weight management, types and amounts of food consumed, and the timing and content of meals. Both encourage people to embrace some foods as “safe” and “good” and fear others as “dangerous” and “bad.”

Control is a central issue in both diabetes and eating disorders. Diabetics may feel guilty, anxious, or out of control if their blood sugar swings more than a few points. Anorexics and bulimics may feel the same way if their weight fluctuates. People with both problems may become consumed with strategies to rigidly control both weight and blood sugar.

Children with diabetes may have parents they perceive as overprotective and overcontroling. The parents of young people with eating disorders are often described in similar terms. In both kinds of families over involvement and enmeshment can lead children to rebellion and dramatic, potentially catastrophic, acts of independence.

People with eating disorders are preoccupied with weight, food, and diet. So are folks with diabetes. In fact, the latter can use their diabetes to hide anorexia or bulimia because, after all, they are supposed to be watching what they eat, and they can blame poorly controlled diabetes for alarming weight loss.

• Are there any other problems related to a combination of diabetes and eating disorders?

Yes. When people misuse insulin to lose weight, sometimes that weight loss seems to improve diabetes, at least temporarily, by reducing or eliminating the need for insulin. It’s interesting to note that starvation was a primary treatment for diabetes before commercial production of supplemental insulin. This weight loss method is not without problems, however. If continued, the person experiences life-threatening organ failure and death.

• What kind of treatment should people who have both diabetes and EDs have?

Getting them into treatment is the first step. Many of these folks are embarrassed to admit that they have been doing something as unhealthy as an eating disorder. Often they defiantly hang onto starving and stuffing behaviors in spite of real threats to life and health. Families sometimes collude by denying that anything is wrong.

Nevertheless, it is important to begin treatment early. Eating disorders can be treated, and people do recover from them, but the longer symptoms are ignored, the harder it is to turn them around and the harsher the effects on the body.

The best treatment is team treatment. That means that many professionals are involved with the patient and perhaps with the family as well: a physician to manage the diabetes and the effects of starving and stuffing, a mental health therapist to help define and deal with underlying emotional issues, a family therapist to help the family, and a dietitian to provide nutritional counseling and education.

The first priority is restoration of physical health. For people with anorexia that means weight gain back to healthy levels. For both anorexics and bulimics the next step is implementation of balanced, varied, and healthy meal plans that provide adequate calories and nutrients. After physical health is stabilized, treatment can focus on the underlying psychological issues.

Most treatment for eating disorders is outpatient, but if the patient is suicidal, severely depressed, or in any kind of medical danger, hospitalization is appropriate until the crisis has passed. Medication may be used to ease depression and anxiety, but it must be carefully monitored by a physician.

• In summary

Diabetes and eating disorders are a nasty combination with very real potential for catastrophic complications, including death. The good news, however, is that in most cases diabetes can be controlled, and eating disorders can be treated. Many people recover from anorexia nervosa and bulimia, but almost always professional help is required.

If you are concerned about yourself, arrange right now to talk to your physician. Don’t let shame or embarrassment stop you from telling the truth. The doctor has heard your story many times before. Ask for a referral to a mental health professional who works with people with eating disorders. Contact that person and ask for an evaluation. Then follow up on any treatment recommendations that come from the evaluation. Other people have made this journey successfully. You can too.

• A postscript from a visitor to our site

Not everone with both diabetes and an eating disorder fits the same profile. There are many variations, one of which is illustrated in the following letter:

Thank you for including this subject on your Website. I want to tell you a little bit about my struggle with diabetes and anorexia, which later led to binge-eating. The person described on your site does not match me, though I have experienced this combination of disorders.

Though I did struggle with both of them, I never used insulin to purge, and my blood sugar levels remained well in control despite my out-of-control eating behavior.

Though there was definately a part of me that wanted to ignore the diabetes, I did not compromise its management. This is an important point because physicians, parents and patients need to know that even when a teenager or adult is “doing well” with diabetes management, they may not be “doing well'” emotionally. They may be restricting food to excess, feeling awful about their perceived defects, and not allowing their feelings to be acknowledged by themselves or others.

K. T.
June 2003