Remuda Ranch

Pregnancy, Fertility, and Eating Disorders

Brenda K. Woods, MD, FAAFP
Lesley Williams, MD
Remuda Ranch Programs for Eating and Anxiety Disorders

“[Y]ou knit me together in my mother’s womb.” Psalms 139:13

Pregnancy and childbirth are miracles repeated everyday on this earth. As physicians who have participated in the births of hundreds of babies, our wonder has never diminished. Although this cycle occurs again and again, the factors that lead to the conception and development of healthy infants require a delicate balance of events easily disrupted by eating disorders (EDs).

Pregnancy often marks a time in a woman’s life filled with joy and expectation at the promise of her unborn child. Of course, some anxiety during pregnancy is also normal. But women with EDs often have significant fears during pregnancy. Women with EDs frequently ask: “Must I gain weight during my pregnancy?” “Will my weight be out of control?” “Will my eating disorder harm my baby?”

EDs occur most often in women during the years of fertility (Crow, Agras, Crosby, Halmi, & Mitchell, 2008). Thus, all clinicians who treat women of reproductive age need to have a heightened awareness of the possibility of ED behaviors and diagnoses. This is particularly true in our present culture, where a recent focus on celebrity pregnancies has contributed to the false impression that a pregnant woman can remain thin throughout pregnancy. Media outlets have even coined the term, “pregorexia,” to describe a woman who is so obsessed with keeping her weight in check while pregnant that she diets and exercises excessively, potentially placing herself and her unborn baby at risk (CBS News, 2008).

Infertility in Women With Active Eating Disorders

Ovulation is the result of a maturation process that occurs in the hypothalamic-pituitary-ovarian axis and is facilitated by a neuroendocrine process terminating in the ovaries. Any alteration in this process results in failure to release a mature ovum, leading to anovulation. Anovulation may manifest in a variety of clinical presentations, but ultimately leads to infertility. If a woman is not regularly ovulating, it is unlikely that she will conceive.

In healthy women, ovulation typically occurs approximately every 28 days, about 14 days before the onset of the menstrual cycle. An indicator of ovulation is regular, predictable menses. Yet many ED patients give histories of irregular menstrual cycles. This symptom is often what leads them to seek medical attention. To meet diagnostic criteria for anorexia nervosa (AN), patients must have three months or more of amenorrhea. In bulimia nervosa (BN) and eating disorder not otherwise specified (EDNOS), the more typical presentation is irregular, unpredictable menses, known as oligomenorrhea. At least 50% of women with BN at normal weight suffer from amenorrhea or oligomenorrhea (Norré, Vandereycken, & Gordts, 2001). This reflects a disruption of the hypothalamic-pituitary-ovarian axis induced by erratic and harmful eating behaviors and/or excessive exercise. It is essential for healthcare providers to explore patients’ eating, dieting, and exercise histories if they present with reports of irregular menses. This may be the opportunity for early intervention in the course of an ED.

Two survey studies found a higher prevalence of EDs in women visiting fertility clinics than in the general population of young women (Stewart, Robinson, Goldbloom, & Wright, 1990; Thommen, Valach, & Kiencke, 1995). This suggests that EDs may be more common in women seeking medical care for infertility, such that EDs are disrupting the hormonal cycle needed for regular ovulation. Other studies looking at groups of women with infertility have been conclusive that EDs are frequently present in women with infertility. AN is present in about 4%, and BN in 12%, of women with infertility; both statistics are four times the national average for young women in general. Alarmingly, EDNOS is diagnosed in nearly 50% of women presenting for treatment of irregular menses (Norré et al., 2001; Resch, Szendei, & Haász, 2004; Stewart et al., 1990). These numbers indicate that all women with infertility issues need to be carefully screened for EDs or sub-clinical ED behaviors. Before aggressive and invasive fertility procedures are performed, a simple and honest dialogue with a caring healthcare professional may discern the true cause of the inability to conceive and prevent costly and risky procedures to the mother. Additionally, it is certainly in the best interest of the future mother and her unborn baby for the mother to be in solid recovery from her ED before she conceives, throughout pregnancy, and during her years of childrearing.

Miscarriage in Women With Active Eating Disorders

It appears that when women with EDs do conceive, they are at greater risk of miscarriage. In addition, women with low BMIs also appear at risk for early pregnancy loss. According to the Danish National Birth Cohort Study of over 23,000 women assessed during 1997-1999, women with BMIs less than 18.5 had a 24% increased risk of miscarriage. This indicates that low weight is a risk factor for miscarriage even apart from the additional risk posed by ED behaviors themselves (Helgstrand & Andersen, 2005). Therefore, women with low BMIs should be counseled, prior to conception, that gaining weight to above a BMI of 18.5 could reduce their risk of pregnancy complications and assure better outcomes. For women with undiagnosed EDs, the thought of gaining weight prior to pregnancy could be very unsettling and may provide clinicians with an opportunity to assist patients in addressing ED beliefs prior to their becoming pregnant.

Diagnosing EDs in outpatient settings can be difficult. In our current healthcare system, appointments with medical providers tend to be brief and provide minimal time for dialogue, especially if the dialogue is not directly about the presenting issue. Fortunately, outpatient providers can ask the following questions to rapidly assist in diagnosing and recognizing patients with EDs. These questions can be a tool for therapists and medical clinicians to screen patients who may be presenting to clinical settings with other chief complaints, but whose issues or demographics raise the possibility of ED diagnoses. The questions are collectively referred to as the SCOFF (Morgan, Reid, & Lacey, 1999). One point is added for every "yes" answer. A score of >2 indicates a likely case of AN or BN.

• Do you make yourself Sick because you feel uncomfortably full?
• Do you worry you have lost Control over how much you eat?
• Have you recently lost more than One stone (15 pounds) in a three month period?
• Do you believe yourself to be Fat when others say you are too thin?
• Would you say that Food dominates your life?

Fertility and Miscarriage Following Eating Disorder Recovery

ED patients entering treatment with hopes of recovery and becoming mothers down the road often ask, “Will I have trouble getting pregnant?” Current findings suggest that when ED behaviors have stopped, women’s ability to become pregnant in the future is not decreased. However, an increased rate of miscarriage has been observed in women with past histories of AN. In one study, which assessed women 15 years post treatment for AN, 38% had miscarried compared to only 16% in a control population (Bulik et al., 1999). This is very worrisome for patients with histories of AN. The cause of the early pregnancy loss is not known. It does appear that after the first trimester, the risk of miscarriage normalizes to what it would have been had there never been an ED. Fortunately, the current research suggests that, after recovery from BN, there does not appear to be any lingering adverse effect on achieving pregnancy or rate of miscarriage.

For ED patients who have miscarried or been unable to achieve pregnancy—whether in recovery from their ED or not—it is obvious that there may be guilt about the possible consequences of their ED choices, and/or grief over a lost child or lost opportunity to become pregnant and have a child. Their partners are also affected and may have a range of feelings, including anger at the ED woman, guilt about not intervening sooner to assist their ED partner with recovery, and doubts about their relationship. This is indeed a complex situation about which little has been written. Fortunately, there are many evidence-based methods that clinicians can utilize to assist patients in dealing with guilt about the adverse consequences of past behavioral choices and finding forgiveness. Grief work is also a staple of mental health counseling. Such general techniques are likely to be of some assistance to clinicians working with ED patients and families in this situation. Although it is beyond the scope of this article to explore these techniques, we offer the following useful resource recommendations from within the Christian counseling arena:

Experiencing God’s Forgiveness: The Journey from Guilt to Gladness, by John Ensor

Make Peace with Your Past, by Tim Sledge

Released from Shame, by Sandra Wilson

Roses in December, by Marilyn Willet Heavilin

Shame and Guilt: Masters of Disguise, by Jane Middleton-Moz

The Art of Giving and Receiving Forgiveness, by John MacArthur

Trusting God Through Tears: A Story to Encourage, by Jehu Burton and Dan Allender

When God Doesn’t Make Sense, by James Dobson

When God Weeps: Why Our Sufferings Matter to the Almighty, by Joni Tada-Eareckson

The Wounded Spirit, by Frank Peretti

In addition, specific techniques exist for working with parents exploring adoption. With a visit to any local or online bookstore, those concerned can find an abundance of such resources for both lay and professional audiences. The unique joys of building an adoptive family can be redemptive and healing for women with past EDs and their partners. The Scriptures hold high the calling to raise adopted children, such that God himself is called “a father to the fatherless” (Psalms 68:5).

Pregnancy and Childbirth During Active Eating Disorders

Crow and associates conducted a prospective investigation of 385 women recruited from three ED treatment centers (Crow, Thuras, Keel, & Mitchell, 2002). They monitored these women for four years. Forty two of the ED women became pregnant during the study interval. As a group, the women showed improvement in their ED behaviors during pregnancy, although their weight gain during pregnancy was not monitored so it is unclear if satisfactory weight gain was attained. The women’s ED behaviors worsened again after delivery. The authors concluded from these findings that pregnancy marks a good time for ED treatment interventions. As such, pregnancy may be a window of opportunity for treating some ED women.

Nevertheless, patients with active EDs need to be considered as having high risk pregnancies. The usual rate of weight gain during pregnancy is a pound a month during the first 20 weeks of pregnancy, then about a pound a week for the remaining 20 weeks. This represents an overall expected weight gain of 25-30 pounds. Koubaa et al. (Koubaa, Hällström, Lindholm, & Hirschberg, 2005) studied women who reported at time of conception that they were in recovery from an ED. The women with AN evidenced lower than expected weight gain during pregnancy. Those with past ED histories had more episodes of hyperemesis gravidarium—severe nausea and vomiting during pregnancy—and 22% relapsed to such an extent that they required ED treatment while pregnant. Therefore, pregnancy is a risk factor for ED relapse and entails possible risks to the fetus through inadequate weight gain.

What are the possible risks to the unborn child? Many studies have explored this issue. Unfortunately, most sample sizes were small and many reports did not state whether the women were actively engaging in EDs during pregnancy. The following pregnancy outcomes are reported by the various studies:

• Increase in preterm deliveries
• More Caesarean sections
• Smaller head circumference in the newborns
• Increased risk of low birth weight

The longer term questions have not been answered. What is the risk to these children? Those born preterm may experience any of a wide range of medical complications known to be associated with preterm delivery. Will these children experience developmental delays or other subtle neuro-psychological issues later on? These questions can only be answered as children of ED mothers are monitored over the years of growth and develop-ment. However, studies of premature births in non-ED women and low birth weight children do indicate adverse long-term developmental effects for these children, including lower IQ, poorer school performance, and reduced occupational achievement (Matte, Bresnahan, Begg, & Susser, 2001; Reichman, 2005).

Working With Pregnant Eating Disorder Women or Those Seeking Pregnancy

The goal of having a child has prompted many women to seek treatment for their ED. This is a time when women may be open to interventions and willing to begin challenging ED belief systems. It is appropriate for clinicians to capitalize on women’s commitment to their unborn or future children. In treatment, patients are often challenged to engage in recovery for themselves rather than for others, but for many this is initially difficult. If a woman is willing to diminish or stop her ED behaviors to give her baby a better chance, this is a window of opportunity that must not be missed. It will help two lives.

Of course, the first step is for the woman to disclose to her healthcare professional that she has an ED. This may require some encouragement by the professional, coaching the patient to be able to be vulnerable and admit to ED behaviors that have long been secretive or embarrassing to her. EDs are often shrouded in secrecy and shame. Patients will often not disclose their behaviors unless they are asked specific questions. Collaboration between mental health professionals and medical care providers can assist in this regard.

The key point to understand is what ED behaviors the patient is engaging in. Is she restricting, or does she binge and purge? Is she taking any pills, such as laxatives or diuretics? By understanding her behaviors, the clinician can then assess the medical risk. For example, a patient may ask her doctor, “May I exercise while I’m pregnant?” A doctor, not understanding the ED, would likely say that the patient can maintain her current exercise schedule. However, if a doctor understands that she is doing three hours of cardiovascular exercise daily, the doctor would not give the same response.

After the patient has disclosed her ED to her care providers, her pregnancy needs to be considered high risk. She should be referred to a registered dietitian for monitoring of her meal plan, education regarding the principles of proper nutrition, and assistance with the normal increase in daily calories needed to sustain a growing fetus. The average woman usually needs 300 extra kcals/day to maintain regular pregnancy weight gain. For the ED patient, especially those with AN, this may prove quite difficult. The physician will need to very carefully monitor the patient’s weight gain and the growth of the fetus. Delayed fetal growth may become more apparent during the third trimester, because growth rate is the most rapid at this time.

Education will also be needed regarding proper exercise during pregnancy. A physician or other trained professional can make appropriate exercise recommendations based on the woman’s pre-pregnancy level of cardiovascular conditioning and overall physical health. Exercise during pregnancy can have positive benefits for the child throughout the child’s life, including enhanced cognitive functioning. However, the risks of exercise in a medically compromised woman must be balanced against these benefits. Unfortunately, sound research to guide such decisions is lacking.

A therapist needs to be actively involved with the patient and perhaps her partner during this critical time. Many issues come up for any woman during pregnancy, but for a woman with an ED, the issues are magnified. The therapist can assist her in dealing with body image concerns which will likely escalate. The therapist can work with the woman on any ambivalence she may have about motherhood and the changes that will occur in her life. The patient’s faith, prayer, and spiritual disciplines may help her to accept with serenity what she cannot change—the alteration to her weight and body shape—and to find joy in participating in God’s creation of a new human life of great value. Relationship issues may also surface between the patient and her partner as they face parenthood. These several psychosocial stressors can be a springboard for positive life changes if the patient is provided with the support of a caring treatment team. Affirming the woman’s ability to be a good mother and a positive role model for her child can give her the hope she needs to face the challenges ahead.

Childrearing by Eating Disorder Mothers

Another pressing issue is the impact of an active ED mother on her children, especially female children. Detailed discussion of this topic is beyond the scope of this article, but it is not uncommon for children and adolescents admitted to Remuda to disclose that their mothers also have EDs. Indeed, EDs run in families. Some portion of this familial association is genetic, but there are also likely to be environmental influences wherein children learn ED concerns, beliefs, and behaviors from their ED parents. Various studies have looked at this and found the following parenting issues to be more common in ED mothers (Agras, Hammer, & McNicholas, 1999; Stein, Woolley & McPherson, 1999; Stein et al., 2001; Stein et al., 2006a; Stein et al., 2006b):

• Three times greater risk of post-partum depression for patients with BN
• Breast feeding difficulties
• Major episodes of mealtime conflict with children
• Interactional difficulties, such as struggle or refusal to allow children to express age appropriate needs for autonomy in the areas of self-feeding and food play
• Continued lower than expected infant and child weight gain
• Perfectionism in parenting
• Preoccupations with food, shape, weight, obsessive thoughts, and post-partum depression interfering with cognitive processes and narrowing the attention given to children

Treatment with ED mothers therefore involves a range of interventions aimed at helping such parents to: deal with potential post-partum depression; respond correctly to their infants’ cues, especially those regarding hunger and satiety; learn about food refusals as normal; develop healthy relationships with, and provide adequate attention to, their children; learn about childhood nutritional needs and developmental expectations and milestones; and set reasonable expectations for their children’s behavior and performance.

Binge Eating During Pregnancy

A long-term investigation of 100,000 pregnant women in Norway revealed an increased risk for binge eating disorder (BED) to arise during pregnancy and continue afterwards, especially among women from lower socioeconomic groups (Bulik et al., 2007). In addition, for women with pre-existing BED, continuation of BED symptoms during pregnancy was common. It remains unclear if fluctuating nutrition during pregnancy due to BED symptoms affects children’s birth weight, development, or post-natal eating and weight patterns. In this light, to offer early intervention it seems prudent to assess pregnant women for BED symptoms—particularly the experiences of losing control over eating and consuming large amounts of food in a set period of time. Early intervention may improve the women’s and children’s short and long term health status.

Conclusion

Pregnancy is a time of change and new beginnings. New life brings with it new hope. Pregnancy can thus be a time for a woman who has struggled with an ED for years to find new reasons to recover. It can also be a time of fear, relapse, and risk for ED women. For these reasons, for the treating professional pregnancy should be the impetus to look for new treatment strategies to work with patients who may have been “stuck” or resistant for months or years. Their worries and hopes for their child combine to open a new window of opportunity for possible change and healing. Another life is at stake; both patient and provider keenly know this and can capitalize on this intense experience to foster therapeutic change.

References

Agras, S., Hammer, L., & McNicholas, F. (1999). A prospective study of the influence of eating-disordered mothers on their children. International Journal of Eating Disorders, 25, 253-262.

Bulik, C.M., Sullivan, P.F., Fear, J.L., Pickering, A., Dawn, A., & McCullin, M. (1999). Fertility and reproduction in women with anorexia nervosa: A controlled study. Journal of Clinical Psychiatry, 60, 130-135.

Bulik, C.M., Von Holle, A., Hamer, R., Berg, C.K., Torgersen, L., Mangus, P., Stoltengerg, C., Siega-Riz, A.M., Sullivan, P., & Reichborn-Kjennerud, T. (2007). Patterns of remission, continuation and incidence of broadly defined eating disorders during early pregnancy in the Norwegian Mother and Child Cohort Study (MoBa). Psychological Medicine, 37, 1109-1118.

CBS News. (2008). ”Pregorexia" inspired by thin celebs? Moms-to-be, obsessing over weight, diet, exercise so much they put baby's health in some jeopardy. Retrieved August 14, 2008, from www.cbsnews.com/stories/2008/08/11/earlyshow/health/main43 37521.shtml

Crow, S.J., Thuras, P., Keel, P.K., & Mitchell, J.E. (2002). Long-term menstrual and reproductive function in patients with bulimia nervosa. American Journal of Psychiatry. 159, 1048-1050.

Crow, S.J., Agras, W.S., Crosby, R., Halmi, K., & Mitchell, J.E. (2008). Eating disorder symptoms in pregnancy: A prospective study. International Journal of Eating Disorders, 41, 277-279.

Helgstrand, S. & Andersen, A.M. (2005). Maternal underweight and the risk of spontaneous abortion. Acta Obstetricia et Gynecologica Scandinavica, 84, 1197-1201.

Koubaa, S., Hällström, T., Lindholm, C., & Hirschberg, A.L. (2005). Pregnancy and neonatal outcomes in women with eating disorders. Obstetrics and Gynecology. 105, 255-260.

Matte, T.D., Bresnahan, M., Begg, M.D., & Susser, E. (2001). Influence of variation in birth weight within normal range and within sibships on IQ at age 7 years: Cohort study. British Medical Journal, 323, 310-314.

Morgan, J.F., Reid, F., & Lacey, J.H. (1999). The SCOFF questionnaire: assessment of a new screening tool for eating disorders. British Medical Journal; 319, 1467-1468.

Norré, J., Vandereycken, W., & Gordts, S. (2001). The management of eating disorders in a fertility clinic: Clinical guidelines. Journal of Psychosomatic Obstetrics and Gynaecology, 22, 77-81.

Reichman, N.E. (2005). Low Birth Weight and School Readiness. The Future of Children Journal, 15, 91-116.

Resch, M., Szendei, G., & Haász, P. (2004). Eating Disorders from a gynecologic and endocrinologic view: Hormonal changes. Fertility Sterility, 81, 1151-1153.

Stein, A., Woolley, H., Cooper, S., Winterbottom, J., Fairburn, C.G., & Cortina-Borja, M. (2006a). Eating habits and attitudes among 10-year-old children of mothers with eating disorders. British Journal of Psychiatry, 189: 324-329.

Stein, A., Woolley, H., Murray, L., Cooper, P., Cooper, S., Noble, F., et al. (2001). Influence of psychiatric disorder on the controlling behaviour of mothers with 1-year-old infants. British Journal of Psychiatry, 179: 157-162.

Stein, A., Woolley, H., Senior, R., Hertzmann, L., Lovel, M., Lee, J. et al. (2006b). Treating disturbances in the relationship between mothers with bulimic eating disorders and their infants: A randomized, controlled trial of video feedback. American Journal of Psychiatry, 163, 899-906.

Stein, A., Woolley, H., & McPherson, K. (1999). Conflict between mothers with eating disorders and their infants during mealtimes. British Journal of Psychiatry, 175: 455-461.

Stewart, D.E., Robinson, E., Goldbloom, D.S., & Wright, C. (1990). Infertility and eating disorders. American Journal of Obstetrics and Gynecology; 163, 1196-1199.

Thommen, M., Valach, L., & Kiencke, S. (1995). Prevalence of eating disorders in a Swiss family planning clinic: A pilot study. Eating Disorders, 3, 324-331.

Diabetes and Eating Disorders

Lesley Williams, MD
Brenda K. Woods, MD, FAAFP
Remuda Ranch Programs for Eating and Anxiety Disorders

[E]ach of you should learn to control his own body in a way that is holy and honorable. 1 Thessalonians 4:4

Thoughts about food, exercise, and body image dominated Lisa’s life. These issues are typical for 13 year old girls like Lisa, but are magnified by Lisa’s type 1 diabetes. Since diagnosis with diabetes at age 10, Lisa went from being happy go lucky and playing soccer to constant worrying about carbohydrate counts, quantities of exercise per week, and changes in her body. As Lisa entered adolescence and began striving for independence, her blood sugars became increasingly difficult to manage. Her parents thought that Diabetes Camp might be a great opportunity for her to spread her wings and work on diabetes management away from their watchful eyes. At camp, Lisa made friends with other adolescent girls with diabetes. She learned that they all shared similar experiences and concerns. She also learned that they have a unique ability to manage their weight by not controlling their blood sugars. When Lisa went home, a year of struggles followed. She frequently withheld insulin to manipulate her weight. But she paid a high price for this. Lisa needed multiple hospitalizations for elevated blood sugars and was ultimately told that her kidneys were being harmed. This reality check led Lisa to acknowledge what her endocrinologist had been suspecting—that she had an eating disorder.

Several studies have demonstrated that eating disorders (EDs) are more common in women and girls with type 1 diabetes (Hoffman, 2001). A review of eight studies with ED patients revealed that the frequency of women and girls with diabetes was at least 50% greater than among non-diabetic controls (Hoffman, 2001). Several reasons why females with diabetes may be at increased risk for ED development have been proposed, including weight gain after diagnosis, body image concerns, need for dietary restriction and food focus, exercise emphasis, the psychological impact of chronic illness, and family dynamics (Herpertz et al., 1998). These issues, coupled with the unique ability of those with diabetes to purge calories by withholding insulin, make diabetes patients especially vulnerable to ED development.

Understanding Diabetes

Individuals with type 1 diabetes mellitus have an autoimmune disorder that renders their bodies unable to produce insulin. Due to mis-education, patients or families may feel that type 1 diabetes is caused by lifestyle choices. Even if the patient has been overweight or “eaten a lot of sugar”, this did not cause type 1 diabetes. These are important educational points to prevent the patient and family from believing that they can cure type 1 diabetes through healthful eating. The only known treatment for type 1 diabetes is providing insulin via injection or insulin pump to replace the function of the pancreas. Insulin is vital to life; it is the key that allows the foods we eat, which are metabolized to glucose, to be used by our cells as fuel. Without insulin, the body literally starves because it cannot use the glucose from food as fuel. Instead, glucose circulates in the bloodstream until excreted from the body in the urine. Elevated glucose levels in the bloodstream can damage blood vessels throughout the body and cause diabetes’ multiple long-term complications, such as kidney failure, heart disease, blindness, nerve damage, growth retardation, and poor circulation leading to limb amputation.

Type 2 diabetes involves a different disease process than type 1 diabetes. Those with type 2 diabetes have decreased insulin production and insulin resistance. In insulin resistance, the body has become less responsive to the insulin present, rendering the insulin less effective. Those with type 2 diabetes account for the majority of individuals diagnosed with diabetes. Obesity is linked to type 2 diabetes because excess fat tissue affects how insulin works and can cause increased insulin resistance. The ED most commonly seen in people with type 2 diabetes is binge-eating disorder (BED) (Colton, Olmsted, Daneman, Rydall, & Rodin, 2004). Typically, the patient’s BED led to obesity, which contributed to the development to type 2 diabetes. Unlike type 1 diabetes, type 2 diabetes can be prevented and reduced through lifestyle changes and weight loss.

Diabulimia

The term, diabulimia, has been coined by the media. Although not a DSM diagnosis, it described the unique form of purging that ED patients with diabetes often engage in. By withholding insulin or giving inadequate doses, these patients can cause their glucose levels to elevate and render their bodies incapable of using the glucose from food as fuel. As such, glucose levels remain high in the bloodstream and the glucose, with its necessary calories, are purged from the body in the urine (Daneman et al., 2002). Several studies have demonstrated that insulin omission for weight control is a common practice among females with diabetes. In one study, 36% admitted to this practice (Bryden et al., 1999).

Weight Loss Followed by Weight Gain

Symptoms of diabetes include increased thirst, frequent urination, and dramatic weight loss. These symptoms are the result of the body being unable to use the glucose from food and subsequently secreting it into the urine. Patients often see the weight loss that occurs in diabetes as a positive side effect. Once the appropriate diagnosis of type 1 diabetes is made and insulin therapy initiated, patients often experience rapid weight gain that may even exceed their initial weight loss. As a result, insulin can be seen as “the enemy,” because it causes weight gain.

Dietary Restriction and Food Focus

Imagine adolescents at a birthday party. This is a great opportunity to indulge in sweet treats and hang out with friends. But for diabetes patients, this situation is wrought with obstacles. They are faced with various “forbidden” foods high in sugar content. Their dietary education has cautioned them to avoid such indulgences. Eating these foods requires large doses of insulin to maintain blood sugar within an acceptable range. This intense focus on food choices and dietary restriction occurs not only at birthday parties, but throughout most days. Adolescents desperately want the freedom to choose the foods they enjoy without having to worry about carbohydrate counts and insulin doses. This conflict and constant food focus from a young age place adolescents with diabetes in a vulnerable state.

Exercise and Diabetes

Exercise has positive effects on types 1 and 2 diabetes. Both types benefit because exercise allows the body to better use glucose in the blood. With exercise, patients may require less insulin administration or oral diabetes medication. For those with type 2 diabetes, exercise decreases body fat and improves insulin resistance, with the added benefit of visible weight loss. Due to these health benefits, healthcare providers often encourage exercise in those with diabetes. Unfortunately, the increased emphasis on exercise makes some patients resistant to participation, and sometimes makes the physical activity that they previously enjoyed seem now like a chore.

Body Image

The Diabetes and Complications Trial examined weight trends of patients using intensive insulin therapy. These patients had fewer diabetes-related complications, but experienced significant weight gain. Of the adolescents studied, 48% became overweight, compared with just 28% of patients using conventional diabetes care (Meltzer et al., 2001). So, when diabetes patients express concern about not wanting to take insulin because it will make them overweight, their fears are not unfounded.

Many studies have demonstrated that body image concerns lead to ED behaviors. Body image concerns often trigger the cycle of dietary restriction, leading to binge-eating, purging, and ultimate weight gain. Females with diabetes are especially vulnerable to this cycle. Studies have shown that, beginning in puberty, they are on average heavier than their non-diabetic peers (Colton et al., 2004). Continued increases in BMI from adolescence to adulthood correlate with ongoing body image concerns and dietary restriction (Bryden et al., 1999). As a result, the frequency of ED behaviors increases with age.

Psychological Impact of a Chronic Illness

Patients diagnosed with chronic illnesses like diabetes go through a grief process in response to the loss of health. The realization that they have an illness that will require lifelong maintenance and may decrease their life expectancy is daunting, especially for adolescents. Fear of potential disabilities, loss of freedom, and premature death is universal. The initial response to such overwhelming information is usually denial. Fear and denial often manifest as neglect for the diabetes and disregard for its consequences (Daneman et al., 2002). Unfortunately, such a response can lead to a host of serious medical complications.

Familial Factors

Successful diabetes management requires a family effort. This can be difficult during the precarious adolescent years. During adolescence, teens strive to obtain independence. Parents, who have historically been very involved in their teenagers’ diabetes management, have a difficult time letting go of this important responsibility. As a result, conflict within the family arises. Familial conflict is one of the many family issues that correlate with poor diabetes-related outcomes. Low cohesion, inadequate structure, poor communication, perceived rejection, and poor boundaries have also been found as contributing factors. It is difficult but crucial for parents of diabetic adolescents to find the delicate balance between sufficient independence and support (Daneman et al., 2002). Counseling may indeed be needed to assist families in achieving this balance.

How Do You Recognize an Eating Disorder in Diabetic Patients?

Many diabetes patients are reluctant to admit that their poor blood sugar management is the result of an ED. Due to the high prevalence of EDs in the diabetes population, clinicians are urged always to screen for potential eating disturbances. Signs to look for include fatigue, increased caloric intake with persistent weight loss, unexplained blood sugar elevations despite interventions, recurrent hospitalizations, multiple episodes of diabetic ketoacidosis, elevated lipids, unwillingness to be observed administering insulin, poor compliance with clinic appointments, and early microvascular disease. If any of the these signs is present, further work-up to evaluate for an ED is warranted.

Determining whether or not an ED exists may require some clever detective work by the clinician. One suggestion is to ask questions like, “How many shots did you skip this week?”, versus “Did you skip any shots this week?” The first option is less threatening and opens the door for the patient to honestly discuss struggles.

Treatment Recommendations

Nutritional counseling should de-emphasize strict insulin therapy and dietary restraint. This approach will promote intuitive eating and enable patients to move away from strict traditional meal and snack times (Hoffman, 2001). Family counseling is also an important component of successful diabetes management. Families need to be involved in tailored therapeutic interventions that improve family communication, boundaries, and interactions, and assist families in striking the balance between independence and support (Daneman et al., 2002). Body image and self-esteem have both improved in patients who became involved in family-based multidisciplinary behavior modification programs (Hoffman, 2001). Body image should clearly be addressed from a therapeutic standpoint as well. Patients require empathy and support because their weight gain concerns are not unfounded. One way to align with them is to acknowledge the possibility of weight gain, but contrast that with the need to maintain adequate blood sugar control to achieve optimal health and long-term life goals (Daneman et al., 2002).

Intensive inpatient care is often needed for patients with a combination of type 1 diabetes and ED. In fact, poorly controlled diabetes is listed in the American Psychiatric Association criteria for inpatient hospitalization in ED patients (American Psychiatric Association, 2006). The inpatient setting is required to provide frequent monitoring and adjustment of insulin dosages and a structured environment to stabilize ED behaviors and enable medical and nutrition teams to be continuously involved. At Remuda, the primary care provider assesses the patient within 24 hours of admission. Laboratory work is obtained to determine current blood sugar as well as average blood sugar over a period of several months (Hemoglobin A1c). Additional studies evaluate the patient for potential damage from uncontrolled diabetes to kidneys and other organs. The physical exam assesses for evidence of damage to the retina and peripheral nerves. Most patients are placed on an evening injection of long acting insulin which provides a basal level of insulin in the blood stream and then are given short acting insulin at each meal and snack to cover the carbohydrates they are eating. This insulin regimen could equal 7 shots a day, not uncommon in the current treatment of type 1 diabetes.

Initially, nurses take the primary role in monitoring blood sugars and supervising insulin administration. This is necessary because most patients have a history of manipulating their insulin doses. As patients progress in treatment, we look forward to their taking a more active role in their diabetes management.

After 60 days of inpatient treatment at Remuda, patients’ average blood sugars typically drop dramatically and move toward the normal range. A range of psychotherapeutic interventions focus on the issues common to those with ED, and also address issues of chronic illness and accepting responsibility for managing a disease that will always be a part of the patient’s life. The spiritual dimension is often a critical part of such treatment. This includes assisting patients to: honor their bodies as temples of God; recognize the true meaning of beauty as defined by God so they are more able to celebrate their bodies as God made them and let go of dangerous efforts to control their weight; understand and accept the redemptive aspects of chronic illness and weakness; and lean on their growing faith and prayer life to cope with struggles and find strength and hope to carry them through the difficulties of ED recovery.

When patients leave inpatient treatment they require close follow-up by a primary care physician and endocrinologist. Aftercare by a registered dietitian is recommended for all ED patients but is essential for those with diabetes. Ongoing diabetic education by a certified diabetes educator can also prove beneficial.

Conclusion

Prayerfully, future medical advances will help us find a cure for diabetes. Currently, the combination of diabetes and ED greatly impacts patients’ morbidity and mortality. Understanding the contributing factors, recognizing the signs, implementing appropriate treatment interventions, and referring to inpatient care when indicated are all vital to improving the clinical outcomes of this unique and difficult to treat population.

References

American Psychiatric Association. (2006). Practice Guidelines for treatment of patients with eating disorders (3rd ed.). Washington, DC: American Psychiatric Association.

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Colton, P., Olmsted, M., Daneman, D., Rydall, A., & Rodin, G. (2004). Disturbed eating behavior and eating disorders in preteen and early teenage girls with type 1 diabetes. Diabetes Care, 27, 1654-1659.

Daneman, D., Rodin, G., Jones, J., Colton, P., Rydall, A., Maharaj, S., et al. (2002). Eating disorders in adolescent girls and young adult women with type 1 diabetes. Diabetes Spectrum, 15, 83-105.

Herpertz, S., Albus, C., Wagener, R., Kocnar, M., Wagner, R., Henning, A., et al. (1998). Comorbidity of diabetes and eating disorders. Diabetes Care, 21, 1110-1116.

Hoffman, R.P. (2001). Eating disorders in adolescents with type 1 diabetes. Postgraduate Medicine, 109, 67-69, 73-74.

Meltzer, L., Johnson, S., Prine, J.M., Banks, R.A., Desrosiers, P.M., & Silverstein, J.H. (2001). Disordered eating, body mass, and glycemic control in adolescents with type 1 diabetes. Diabetes Care 24, 678-682.