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Breaking Bulimia

Breaking Bulimia

We have all been there: turning to the refrigerator if feeling lonely or bored or indulging in seconds or thirds if strained. But if you suffer from bulimia, the from time to time urge to overeat is more like an obsession.

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Bulimia Help Method

Endorsed by University Professors, Eating Disorders Specialists, Doctors and former bulimics, the Bulimia Help Method is a proven & trusted approach to lifelong recovery from bulimia. The Bulimia Help Method home treatment program gives you the insight, skills and tools needed to break free from bulimia and to make peace with food and your body. You are guided step-by-step along the way so you always know what to expect and what to do next. A powerful audio program will help to reprogram your old eating habits at a sub-conscious level, speed up your recovery and help you feel more calm and grounded.

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Diabetes And Eating Disorders Epidemiology And Clinical Features

There has been controversy in the literature about the association of eating disorders and DM1 (50). However, the evidence from methodologically rigorous studies and from a meta-analytic review (51) supports the view that there is an increased risk for both subthreshold and full-syndrome eating disorders in girls and women with DM1. In studies using a diagnostic interview, the prevalence of full-syndrome eating disorders in girls and women with DM1 ranged from 0 to 11 , and the prevalence of subthreshold eating disorders from 7 to 35 (52-60). An increased risk of disturbed eating behavior in girls with DM1 can be detected even in the preteen years, with disturbed eating behavior reported by girls as young as 9 and 10 years of age (52). There is no clear association between DM2 and disturbed eating behavior, although this relationship has been less extensively investigated in DM2 than in DM1. Binge eating disorder appears to be the most common eating disorder in those with DM2 (61). It...

Eating Disorders And Depression Screening And Treatment

In view of the high rates of both depression and eating disorders and their medical consequences in girls and women with diabetes, regular screening for these problems should be incorporated into their primary medical care, beginning in the preteen years. Questions about persistent mood alterations, loss of interest in activities, lowering of motivation or energy level, or sleep problems, can reveal the presence of a mood disturbance. Enquiry about satisfaction with weight and shape, dieting, binge eating and weight-control behavior can uncover difficulties with body image and eating behavior. There are well-validated self-report screening measures for both depression and eating disorders that can be useful in the medical clinic setting. Scales commonly used to screen for depressive symptoms in this context include the Center for Epidemiologic Studies Depression Scale (122), the Beck Depression Inventory-II (123) and the PHQ-9 (124). Appropriate screening measures for eating disorders...

Eating Disorders And Depression An Introduction

Eating disorders are a group of psychosomatic conditions characterized by disturbed eating behavior and a constellation of psychological traits and symptoms. Disturbed eating behavior refers to dieting and fasting, binge eating episodes and compensatory behavior for weight control. The latter includes excessive exercise for weight loss, and purging behavior, such as self-induced vomiting and the abuse of laxatives, diuretics and diet pills. Individuals with diabetes have an additional purging behavior available to them, namely, the dangerous practice of deliberate insulin dosage manipulation or omission to promote weight loss. This behavior has more recently been named diabulimia. By decreasing, delaying or eliminating prescribed insulin doses, an individual can induce hyperglycemia and rapidly lose calories in the urine, termed glycosuria. Less dramatic neglect of insulin therapy, such as irregular blood sugar monitoring and inadequate adjustment of insulin dosage to compensate for...

Signs of anorexia or bulimia

Young girls with eating disorders (and young boys about a tenth as often) either starve themselves and exercise excessively or eat a great deal and then induce vomiting and or take laxatives and water pills. Someone who starves herself has anorexia nervosa, while someone who binges and purges has bulimia nervosa. By themselves, these conditions can result in severe illness and even death when carried to extremes. When combined with diabetes, the danger increases greatly. Anorexia is usually found in middle- and upper-class girls. They have a distorted body image and are fearful of weight gain. The prevalence may be as high as 1 in 200 in these girls. Their parents are usually very concerned with People with anorexia are in a constant state of starvation. When they have diabetes, their condition is just like that of people with type 1 diabetes before the availability of insulin. They have very low blood glucose levels, so little or no insulin is required (see Chapter 10). They develop...

Effective treatment for eating disorders in people with diabetes

Eating disorders may be responsive to psychotherapy. Once again, the number of published intervention studies is small, and several of the studies which have been published lack rigour, statistical power, control groups and follow-up measures. With these caveats in mind, one finds in the literature some evidence that psycho-education directed toward specific cognitive distortions may be effective for individuals with mild to moderate eating disorders in the early stages83. Psycho-educational therapy is a highly structured treatment programme in which therapeutic milieu and didactic instruction are used to help patients understand the nature, aetiology and complications of disordered eating behaviours. The purpose of this intervention is to foster attitudinal and behavioural change in the patient.84 Psychotherapeutic interventions should address the complex of underlying issues which often cause and sustain eating-disordered behaviour. These issues include depression, diminished...

Eating disorders in diabetes may be particularly devastating

There are some indications that eating disorders in patients with diabetes are more severe than these same disorders in those without diabetes. Hillard and Hillard73 note many similarities in the eating-disordered behaviours and aetiology of people with type 1 diabetes and people who do not have diabetes. These similarities include the type and symptoms of their eating disorder, underlying personality structure, family history of eating disorder, and other psychiatric diseases. In the same article73 however, Hillard and Hillard point out a unique and uniquely troubling feature of eating-disordered behaviour common to many young people with diabetes insulin purging. Recent research48 suggests that between one-third and one-half of all young women with type 1 diabetes frequently take less insulin than they need for good glycaemic control in order to control their weight. Eating disorders have especially devastating consequences for a person with diabetes. Eating disordered behaviour,...

Eating disorders in diabetes

Perhaps because of the constant emphasis on food and diet in diabetes, eating disorders are more common than is realized. Eating disorders associated with diabetes range from restriction of carbohydrate or omitting meals to reduce the blood glucose to a more sinister severe carbohydrate restriction to reduce the insulin dose and reduce weight. Some anorexic patients deliberately induce insulin deficiency and hypergly-caemia to lose weight. They tend to be admitted in biochemical chaos and ketoacidosis. (Laxative abuse and insulin deficiency cause dangerous hypokalaemia.) Anorexia nervosa may alternate with bulimia. Bulimia produces gross fluctuations in glucose balance as the overeating may need large insulin doses, but the self-induced vomiting then precipitates hypoglycaemia. Such patients should be referred to a specialist diabetes service and be seen in conjunction with psychiatric and psychological support. Abnormal eating patterns may persist for many years before being detected...

Eating Disorder Not Otherwise Specified

Some eating disorders have unique features that cause them to not fit one of the generally accepted categories of eating disorders (e.g., anorexia, bulimia). To address this problem, DSM-IV identifies a diagnosis known as eating disorder not otherwise specified (ED-NOS). Examples of eating disturbances that would fit this diagnostic profile include a person who purges after eating only a small amount of food or a person who has lost a significant amount of weight by starving themselves but their weight still technically falls in a healthy range. risk for potentially irreversible complications, this tactic does successfully result in weight loss. For individuals with DM1 who are rigidly fixated upon weight loss, to the exclusion of long-term DM1-related health concerns, diagnosis and treatment of the eating disorder become imperative.

Handling Eating Disorders

Children, especially girls, are often convinced that they're too fat, even when there's little or no evidence to support it. When the attempt to lose weight becomes dangerous to the health of the patient, it's an eating disorder. Eating disorders take two different forms anorexia nervosa and bulimia. I describe the differences in the context of someone with T1DM and provide sources of help in the following sections. An eating disorder is particularly dangerous in a child with T1DM because she tends to reduce or stop her insulin, knowing that insulin is required to store fat. She can rapidly get into ketoacidosis (see Chapter 4). If you suspect that your child has an eating disorder, take her to her endocrinologist for a discussion, and get a recommendation for a therapist who handles eating disorders. They can be very complicated and very dangerous.

Eating Disorders

Eating disorders occur among people with diabetes just as they do in the general population. Some researchers believe that individuals with diabetes may have an increased risk for eating disorders because they have to pay more attention to what they are eating. Unfortunately, in our society, the self-worth of many people comes from having a perfect body. Some people resort to extreme measures to get or stay thin. There are two main eating disorders anorexia nervosa and bulimia. Each has a distinct set of warning signs. People with anorexia refrain from eating in order to stay thin. Their percep tion of their body is often out of tune with reality. Even very thin women sometimes perceive themselves as being overweight. People with bulimia will often eat normal or even excessive amounts of food and then purge the food by inducing vomiting or taking laxatives. Over time, bulimia can cause problems with the esophagus, as well as many dental problems. Both disorders stress the body and...


Bulimia nervosa is characterized by episodes of binge eating, followed by a variety of compensatory methods to negate the increase in calories consumed (e.g., purging through vomiting, excessive exercise, using laxatives or enemas, starvation). A binge is defined Bulimia is diagnosed in approximately 1 to 3 of the population, with males displaying one-tenth the rate for females (71). Since individuals with bulimia often appear physically healthy and are not grossly underweight, prevalence may, in fact, be much higher. In addition, 30 of those with bulimia show a lifetime diagnosis of comorbid disorders, such as substance abuse or dependence disorder (71). A meta-analysis of controlled studies composed of 748 persons with diabetes and 1587 female participants found that patients with DM1 are significantly more likely to develop bulimia when compared to those without diabetes (75). In addition, it is also estimated that 60 to 80 of people with DM1 engage in episodes of binging at a...


Anorexia is often the easiest of the eating disorders to diagnose because the physical symptoms are difficult to keep hidden. The symptoms, refusal to maintain a minimally normal body weight (characterized as less than 85 of what is appropriate for an individual's height), an intense fear of gaining weight, severe disturbances and perceptions about the shape of the body, amenorrhea, preoccupation with food, the hoarding of food, concerns about eating in public, cooking for others but refusing to eat, and rigid thinking (71), may readily become apparent to family, friends, or medical professionals. A meta-analysis that reviewed five controlled studies, found that individuals with DM1 are at no greater risk for developing anorexia than the general population (72). However, an estimated 1 of all females develop anorexia at some point in their lives, and approximately 10 of people with anorexia will die from complications such as starvations, suicide, or an electrolyte imbalance,...

Anorexia nervosa

Anorexia nervosa is the form of eating disorder in which the patient starves herself. Her weight is at least 15 percent lower than the appropriate weight for her height and age either as a result of starvation from a normal weight or from never allowing herself to reach a normal weight. She looks in the mirror and sees fat where others see thin or even starvation. Anorexia is more common in girls than boys. These girls often get their erroneous ideas about body weight from their mothers who are preoccupied with staying thin. Patients tend to come from middle-class or upper-class families. They often love to cook, but only for others they won't taste the food themselves. One clue that anorexia is present in someone with T1DM is that the person requires very little insulin because she's taking in so little food, especially carbohydrates. In fact, it's difficult to calculate her insulin needs at all. Other findings that suggest anorexia are low body temperature and low blood pressure as...

Dietary prevention of chronic heart failure CHF the role of micronutrients dietary fatty acids and reduced sodium intake

There is not room here to fully explore the present knowledge in this field. Nevertheless, if we restrict our comments to human data, the situation can be summarised as follows. Cases of hypocalcaemia-induced cardiomyopathy (usually in children with a congenital cause for hypocalcaemia) that can respond dramatically to calcium supplementation have been reported.67 Hypomagnesaemia is often associated with a poor prognosis in CHF,68 and correction of the magnesium levels (in anorexia nervosa for instance) leads to an improvement in cardiac function. Low serum and high urinary zinc levels are found in CHF,69 possibly as a result of diuretic use, but there are no data regarding the clinical effect of zinc supplementation in that context. In a recent study, plasma copper was slightly higher and zinc slightly lower in CHF subjects than in healthy controls.58 As expected, dietary intakes were in the normal range and no significant relationship was found between dietary intakes and blood...

Spectrum of Clinical Presentation

Type 2 diabetes is a heterogeneous disorder and is especially apparent among the elderly. Many survivors of middle-age onset diabetes have established micro and macrovascular complications and other co-morbidities. As is usual with a long duration of disease, these patients often require insulin treatment and may display labile glucose levels more typical of insulin-deficient or type 1 diabetes. Other patients with many years of diabetes have more stable glycemia, possibly because of preserved endogenous insulin production, and may be well controlled on simple oral therapy regimens. Need for anti-diabetic treatment may actually decline in some older patients because of weight loss, anorexia and declining renal function.

Dieting Body Image Problem

There is a culture of body image in our society, thus it is important to pay close attention to the behavioral and mental health concerns for children and adolescents. The American Academy of Pediatrics Diagnostic and Statistical Manual for Primary Care (DSM-PC) distinguishes dieting body image behaviors that were, in the past, difficult to categorize as eating disorders. Children and adolescents may exhibit behaviors that do not meet full DSM-IV criteria, yet still deserve attention. The two specific complexes in the DSM-PC-related diagnostic categories include dieting body image behaviors and purging binge-eating behaviors (125). There are two levels of pathology for both of these behavior patterns in children that do not fulfill DSM-IV criteria for an eating disorder. In DSM-PC, variations constitute minor deviations from normal that still might be of concern for a parent or clinician (125). An adolescent with a dieting body image problem will be one who exhibits voluntary food...

Pathophysiology Of Macrosomia

Pathophysiology Undernutrition

The familial clustering of type 2 diabetes can indicate environmental rather than genetic causation. In a study of physical, behavioral, and environmental characteristics of 42 parents and siblings in 11 families of adolescents with type 2 diabetes, 5 mothers and 4 fathers had diabetes before the study and it was diagnosed in 3 of the remaining fathers during the study. All 42 relatives had BMI 85th percentile and skin fold measurements 90th percentile. Fat intake was high and fiber intake low physical activity was nil to low. Eating disorders were common and diabetes control poor (48).

Emphysematous Cholecystitis

Although clinically similar to acute cholecystitis, some differences are notable. This condition has a male predominance, gangrene of the gallbladder and perforation are more frequent, and the overall mortality is substantially higher (15 vs less than 4 ) than in patients with acute cholecystitis. The clinical manifestations may be otherwise indistinguishable from acute cholecystitis. Patients may present with biliary colic, anorexia, nausea, vomiting, and fever with chills. Toxicity is marked and jaundice may develop in the late stages because of obstruction of bile ducts. The gallbladder may be palpable in one-quarter to one-half of patients. Murphy's sign (characteristic tenderness on palpation of the right upper quadrant) may be absent in some cases because of underlying diabetic neuropathy. Crepitus on palpation is an omnious sign. Gangrene,

4. V. Emanuele N F. Swade T And Ann Emanuele M. Consequencies Of Alcohol Use In Diabetics. Alcohol Health And Research

Confronting a rising tide of eating disorders and obesity treatment vs. prevention and policy. Addict Behav 1996 21 755-65. National Institute of Mental Health. Eating disorders facts about eating disorders and the search Papelbaum M, Appolinario JC. Prevalence of eating disorders and psychiatric comorbidity in a clinical sample of type 2 diabetes mellitus patients. Rev Bras Psiquiatr 2005 27 135-8. 84. Wing RR, Nowalk MP, Marcus MD, Koeske R, Finegold D. Subclinical eating disorders and glycemic control in adolescents with type I diabetes. Diabetes Care 1986 9 162-7. 85. Wolff GE, Clark MM. Changes in eating self-efficacy and body image following cognitive-behavioral group therapy for binge eating disorder a clinical study. Eat Behav 2001 2 97-104.

Clinical Emergencies in Diabetes Diabetic Ketoacidosis and Hyperosmolar Nonketotic Syndrome

Preceded by polyuria (due to osmotic diuresis), the clinical picture begins with anorexia, nausea, vomiting (which precludes oral fluid intake) and, often, abdominal pain (periumbilical and constant) which can mimic a surgical emergency. If treatment is not started, alterations in consciousness ensue, which may evolve to frank coma. Physical signs are due to dehydration and acidosis and include sweet, sickly smell of the patient's breath, deep and rapid respiration (Kussmaul respiration), low jugular venous pressure and tachycardia. In most severe cases, vascular collapse and acute renal failure may develop. White blood cell count may be markedly elevated, even in the absence of infection. Body temperature is normal or tendencially low, unless infections develop.

Growth Puberty And Diabetes Insulin Deficiency And Resistance

Physical growth and development is a major feature distinguishing the child and adolescent from the mature adult. The major pathologic cause of impaired growth and maturation is inadequate nutritional supply to growing tissues, providing the basis of growth failure in most chronic diseases of childhood (2). Diabetes may be considered an example of cellular malnutrition, whereby relative insulin deficiency leads to suboptimal or, frankly, inadequate nutrient supply to the tissues. Whereas, in childhood, the gross effect is impaired linear growth, in adolescence, an added effect is delayed or slowed pubertal development, similar to that seen in eating disorders (3). The degree of impaired growth and pubertal development relates to the inadequacy of diabetic control over time, the most extreme example being Mauriac's syndrome, the triad of growth failure, hepatomegaly, and obesity, first described in the 1930s (4). There have been many subsequent reports of delayed growth and puberty in...

Drug And Insulin Treatment For Type Diabetes Mellitus

Gastrointestinal side-effects are common and include diarrhea, anorexia, dyspepsia and a metallic taste in the mouth. To minimize the occurrence of side-effects, patients should be started on a low dose. Weight gain is usually not a problem with metformin, possibly because it has a slight anorectic effect. Lactic acidosis (which led to the withdrawal of phenformin) is a potentially serious side-effect of metformin therapy, but is rare and unlikely to occur if the drug is not

Skipping Insulin for Weight Loss Can Be Deadly

This behavior is common among diabetic teen girls and young women with an eating disorder called bulimia. Usually, people with bulimia repeatedly eat huge amounts of food and then force themselves to vomit. However, diabetic girls who do not take enough insulin can eat anything they want and still lose pounds without throwing up. Doctors have begun calling them diabulimics and say that this behavior affects approximately one-third of all diabetic young women.

How do you manage a patient with findings of severe peripheral diabetic neuropathy but without symptoms

The most probable diagnosis is gastroparesis. It occurs both in Type 1 and Type 2 diabetic persons and is one of the most severe diabetic complications, because it adversely affects metabolic control and quality of life. It is not, however, associated with other complications or with higher mortality. Gastroparesis can also occur acutely, in cases of diabetic ketoacidosis, but in that case is reversible. It is due to a combination of disturbances (decrease in intensity of gastric muscular contractions, lack of synchronization between gastric and duodenal motility, pyloric spasm) owing to damage of the gastric pacemaker at the fundus of the stomach that regulates motility. Gastroparesis symptoms are morning nausea, burping, flatulence, epigastric pain, early satiety and post-prandial vomiting. The most characteristic symptom of gastroparesis is vomiting of undigested food consumed several hours prior (8-12 hours) or even days before. Symptoms can have exacerbations and remissions or...

Cognitive Function And Depression

Older people with diabetes who are subject to major lifestyle changes, vascular complications and chronic ill-health may well have symptoms of clinical depression. It is important to exclude depression as a cause of cognitive impairment, as people with diabetes are more likely to be depressed (Sinclair and Croxson 1998). Indeed, the presence of depression appears to increase the risk of diabetes two-fold (Eaton et al 1996). In the presence of depressed mood, anxiety symptoms, withdrawal phenomena, and anorexia, depression must be excluded. Simple screening tests such as the Geriatric Depression Score can be used. Other explanations of cognitive impairment in diabetes can include cerebral atrophy and cerebrovascular disease (Tarcot et al

Morbidity And Mortality

Transplantation provides the best renal replacement option for diabetic patients with ESRF, improving the quality of life (3,4), and resulting in less neuropathy and anorexia. Unfortunately, renal transplantation does not improve pre-existing metabolic conditions such as dyslipidaemia or bone disease. These continue to progress and contribute to the long-term morbidity and mortality. The medications used to prevent graft rejection also contribute to metabolic risk factors, including weight gain and metabolic bone disease.

Patricia A Colton and Gary Rodin

Eating Disorders And Depression An Introduction Diabetes And Eating Disorders Epidemiology And Clinical Features Eating Disorders And Depression Screening And Treatment The close relationship between the physical and mental health of individuals with diabetes has been clearly demonstrated. This is most evident in eating disorders and depression, two common mental health problems in women with diabetes. The presence of either or both of these problems can interfere significantly with the ability to achieve optimal metabolic control and can lead to an increased risk of diabetes-related medical complications. There is a substantial female preponderance in the occurrence of eating disorders, due to gender-related factors. Depression is also more common in women, an association that has been linked to socioeconomic factors and adverse life events experienced more frequently by women. Effective treatments are available for both of these comorbid conditions, although evidence suggests that...

Depression And Diabetes

In these conditions, depression is linked to factors such as physical distress and disability, disease severity, prior history of depression and low social support (81). Like eating disorders, depressive symptoms occur along a continuum of severity, and the threshold for clinical concern and intervention should be lower when associated with diabetes than in nonmedical populations. The increased health risks associated with depression when comorbid with either eating disorders and or diabetes is likely due to both biological and behavioral mechanisms. Both depressive symptoms (99, 116) and eating disorders (55, 66) can independently have adverse effects on metabolic control, likely via both behavioral and neuroendocrine pathways. Impaired memory, motivation and problem-solving in either condition, intentional insulin omission in those with eating disorders, and effects of depression on the hypothalamic-adrenal axis and the degree of insulin resistance (86) can all affect metabolic...

Your Childs Changing Role

It is not uncommon for your children and teenagers to feel depressed. Eating disorders, especially among girls, are common. One type of eating disorder among teens with diabetes involves skipping insulin. This allows a person to eat and not gain weight. If you start to suspect that your child is depressed or developing any sort of coping problem, eating disorder, or behavioral problem, seek the help of a professional counselor immediately (see page 264 for more on eating disorders).

Initiation of Renal Replacement Therapy

Dialysis treatment partially reverses insulin resistance, so that insulin requirements are often less than before dialysis. Even patients with type 1 diabetes may occasionally lose their need for insulin, at least transiently, on institution of HD. In other patients, however, insulin requirements increase, presumably because anorexia is reversed so that appetite and food consumption increase. It is most convenient to use a dialysate that contains usually about 200 mg dL of glucose. This allows insulin to be administered at the usual times of the day, reduces the risk of hyperglycemic or hypoglycemic episodes during dialysis, and also causes less hypotensive episodes. Because of anorexia and prolonged habituation to dietary restriction, the dietary intake of diabetic patients on HD often falls short of the required intake of energy (30-35 kcal kg d) and protein (1.3 g kg d). By X-ray absorptiometry, Okuno documented a decrease in body fat mass in diabetic compared with nondiabetic...

Summary And Conclusions

In this chapter I have reviewed counselling and psychotherapeutic interventions for patients with diabetes who are having difficulties coping with the day-to-day demands of life with diabetes, and for patients with diabetes who suffer from frank psychopathology, specifically depression, anxiety disorder or eating disorder. Since the effects of coping problems and psychological disorders may be especially malevolent for people with diabetes, effective psychological treatment is especially important for these individuals. Psychological problems of any magnitude may affect metabolic control directly via the neuroendocrine and physiological effects of stress, or indirectly via a cascade of events, including worsened self-care and deteriorating metabolic control, which may in turn exert a negative reciprocal effect

Treatment for Comorbid Diabetes and Dysregulated Eating

Once an eating disorder or any pattern of disordered eating is diagnosed, treatment should begin immediately. Patients may require inpatient treatment in either a medical or psychiatric hospital, if their eating disorder is particularly severe, or their health is at immediate risk. An example of this circumstance, which is most relevant to people with diabetes, is a person who has intentionally omitted so much insulin from their regimen that they have entered a state of ketosis and require an intravenous insulin drip in order to normalize their blood sugar. After immediate physical danger has been eliminated or ruled out, long-term treatment can begin. Because of the increased risks associated with having both DM1 and an eating disorder, an interdisciplinary team should be utilized in order to address the complex nature of the problem. Ideally, the team should include a psychotherapist, diabetes educator, endocrinologist, and nutritionist. These professionals should be in regular...

Relationship of Dysregulated Eating to Medical Outcomes

An eating disorder can be a life-threatening illness for anyone, but for a person with diabetes it is even more dangerous. Eating disorders greatly increase the mortality and morbidity rate among people with DM1. The majority of research has found that having an eating disorder is linked to increased medical complications for people with diabetes (78). As a result, screening for eating disorders should be implemented as part of routine care for people with diabetes in order to prevent the development or exacerbation of diabetes related complications secondary to dysregulated eating patterns. Multiple self-report measures that are reliable and valid are available to assist with screening and diagnosis of dysregulated eating however, most are not specific to those with diabetes (79).

Clinical Barriers To Optimal Glycemic Control

Maintenance of near-normal glucose levels is demanding, in that it requires an educated and motivated patient to coordinate the complex task of adjusting insulin doses based upon ambient glucose levels, dietary intake, activity, illness, or stress. Although psychosocial barriers such as lack of economic or social support, poor access to specialized centers, eating disorders, and other psychological problems are associated with poor control (6), factors inherent in insulin therapy contribute to the challenge of keeping glucose levels in the near-normal range (Table 1).

Introduction classifying diabetes

Type 2 diabetes is a heterogeneous syndrome both in terms of aethiopathogenetic mechanisms and phenotypic aspects. Type 2 diabetes is the primary result of either insulin resistance or deficiency in insulin secretion, each having a completely different clinical perspective and presentation is usually characterized by a mixture of the two. A genetic predisposition is the most important aspect environmental factors (eating disorders, reduced physical activity, overweight, obesity) precipitate and favour progression of the disease. It is very difficult to determine the incidence of type 2 diabetes because many recent onset cases of diabetes go undiagnosed owing to the absence of overt symptoms. However, current studies have shown that incidence varies from 1 case per 1000 year in the industrialized world to 25 cases per 1000 year in the Pima Indians. The observed differences among populations and ethnic groups reinforces the relevance of genetic and environmental factors.

Obesity And Type Diabetes

Of concern also is that obesity, or the fear of it, can have detrimental effects, particularly in young (predominantly female) patients with Type 1 diabetes. The desire to remain thin can lead these patients to reduce or omit insulin dosages and or to engage in purging and laxative abuse (14-16). This particular form of'eating disorder' is probably one of the prevailing causes of 'brittle' or unstable diabetes, and often leads to recurrent episodes of diabetic ketoacidosis with an increased risk of developing chronic diabetic complications and of premature death (17). Consideration should therefore be given to the management of those with Type 1 diabetes who are obese or at risk of becoming obese, and to vulnerable individuals who are in danger of adversely controlling their own treatment for fear of becoming obese. It remains true, however, that the prevalence of being overweight in Type 1 diabetes is lower than that in the general population (13).

Practical Implications For Diabetes Care

One area in which it is essential to offer help as soon as possible is if you have concerns over young people's eating patterns and or insulin manipulation, particularly in girls aged between 15 and 20 years. The problem of weight gain during puberty, with optimal blood glucose control, is a cause of concern for many teenage girls. Add to this the focus on diet restrictions inherent in diabetes management, it is not surprising that eating patterns are an issue of concern to many parents and professionals alike. Most prevalent (subclinical) eating disorders are binge eating and bulimia nervosa. Early warning signs to be alert to include recurrent DKA, growth failure, recurrent (severe) hypoglycaemia, dieting, extreme low or high HbA1c. In addition to the strategies already discussed, a couple of other issues are important to consider with young people, if disordered eating patterns are to be prevented. Body dissatisfaction is common, if not the norm in adolescent girls, and...

Meglitinide analogues

The risk of hypoglycaemia associated with the recently introduced meglitinide analogue class of rapid-acting secretagogues appears to be lower than that observed with some sulphonylureas this is particularly relevant among patients with erratic meal patterns. Repaglinide is a benzamido derivative that is taken with meals. It has a short duration of action and does not stimulate insulin release in the absence of glucose. If a meal is not taken, the corresponding dose of repaglinide should be omitted. Repaglinide appears to be safe in patients with mild to moderate renal impairment, although caution is required. Nateglinide is an amino acid derivative that, like repaglinide, is marketed as a prandial glucose regulator. The rapid and relatively short-lived insulin secretion that these drugs produce, in the presence of adequate b-cell reserve, reduces postprandial glucose excursions however, the meglitinides also lower fasting plasma glucose concentrations, repaglinide being more...

The functional properties of vitamin D in preventing heart disease

Excessive intake of vitamin D in fortified food, over-the-counter supplements or excessive ingestion of anti-rickets pharmaceuticals can result in vitamin D poisoning. An acute toxic dose has not been established but the chronic toxic dose is more than 5O OOO IU day in adults for 1-4 months and, in children, 4OO IU day is potentially toxic. Acute toxicity effects may include muscle weakness, apathy, headache, anorexia, nausea, vomiting, and bone pain. Chronic toxicity effects include the above symptoms and constipation, anorexia, polydipsia, polyuria, backache, hyperlipidemia, and hypercalcemia. Hypercalcemia may cause permanent damage to the kidney (see http emerg topic638.htm). Arterial hypertension and aortic valvular stenosis can also result from hypervitaminosis D.

Different types of disorders

Both anorexia and bulimia are eating disorders, but they have some differences. For instance, anorexia involves starvation, and bulimia involves binge-ing and purging. I explain the signs, complications, and treatment of both disorders in the following sections. If you think you or your child has an eating disorder, try answering the questions at You can quickly rule it in or out with this questionnaire.


The number of documented cases of eating disorders among people with diabetes appears to be growing47'48. While it is not clear whether these disorders are more prevalent among people with diabetes than they are in the general population49, eating disorders have been associated with poor glycaemic control and an increased risk for retinopathy48. Depression, anxiety disorders and eating disorders can be treated effectively, but all tend to recur and require repeated treatment. A detailed discussion of depression, anxiety disorders and eating disorders among people with diabetes follows, along with counselling and psychotherapeutic treatment modalities for each disorder.

Weight Gain

The association of weight gain with insulin therapy can be a barrier to adherence to prescribed insulin regimen, leading to poor glycemic control (10). Eating disorders occur in up to one-third of females with type 1 diabetes, with intentional omission of insulin representing the predominant weight-control behavior. Compared to females with type 1 diabetes without disordered eating, those inflicted with disordered eating have higher glycosylated hemoglobin levels and are at significantly higher risk for microvascular complications (15).

Hyperglycemic crisis

The most common precipitating factor in the development of DKA or HHS is infection. Other precipitating factors include cerebrovascular accident, alcohol abuse, pancreatitis, myocardial infarction, trauma, and drugs (steroids, antipsychotics, thiazide diuretics, etc.). In addition, new-onset type 1 diabetes or discontinuation of or inadequate insulin in established type 1 diabetes commonly leads to the development of DKA, which may be recurrent in some patients with psychologic problems complicated by eating disorders.

Eating wisely

Chapter 8 discusses how to count carbohydrates so that your child takes the right amount of insulin for the food that he eats. I explain how to include the right mix of protein, fat, vitamins, minerals, and water along with carbohydrates the diet challenges you face when you feed a child of any age and how to take other food factors into account, such as sugar substitutes and fast food. I also offer advice on coping with eating disorders.

Glycemic Control

On the other hand, the half-life of insulin is prolonged, predisposing to hypoglycemic episodes. This risk is further compounded by anorexia and by cumulation of most sulfonylurea compounds (with the exception of gliquidone or glimerpiride). Glinides and glitazones do not cumulate, but long-term safety data in renal failure are not available.

Dan Ziegler

Acute painful neuropathy has been described as a separate clinical entity (16). It is encountered infrequently in both type 1 and type 2 diabetic patients presenting with continuous burning pain particularly in the soles ( like walking on burning sand ) with nocturnal exacerbation. A characteristic feature is a cutaneous contact discomfort to clothes and sheet which can be objectified as hypersensitivity to tactile (allodynia) and painful stimuli (hyperalgesia). Motor function is preserved, and sensory loss may be only slight, being greater for thermal than for vibration sensation. The onset is associated with and preceded by precipitous and severe weight loss. Depression and impotence are constant features. The weight loss has been shown to respond to adequate glycemic control, and the severe manifestations subsided within 10 months in all cases. No recurrences were observed after follow-up periods of up to 6 years (16). The syndrome of acute painful neuropathy seems to be equivalent...

Sources of help

If you think that your child with T1DM may have an eating disorder and would like to know more about anorexia and bulimia, check out the following resources i The Eating Disorder Referral and Information Center Find information and treatment centers online at You can also contact the center at 2923 Sandy Pointe, Suite 6, Del Mar, CA 92014-2052 or call 858-792-7463. 1 The National Eating Disorders Association You can find information i The National Association of Anorexia Nervosa and Associated Disorders Find information online, including referrals to support groups, therapists, and treatment centers, at You can also contact the association at P.O. Box 7, Highland Park, IL 60035 or call 847-831-3438.


Puberty is a time of peak growth similar to the first year of life. The adolescent gains the last fifth of his height and 50 percent of his adult weight. Strength greatly increases, especially if he does strength-training exercises. Girls have their pubertal growth spurt earlier than boys, but boys experience a longer growth period and are taller on average at the end of growth. The percentage of body fat in boys remains about the same but significantly increases in girls, sometimes leading to the eating disorders described in Chapter 8.


The most common and troublesome side-effects of metformin include gastrointestinal discomfort, nausea, diarrhea, anorexia, and rarely a metallic taste (Dandona et al 1983). Starting therapy with 500 mg daily and increasing the dose gradually can attenuate these side-effects. The biguanide-associated malabsorption of vitamin B12 (cyanocobalomin) and folate is usually not a major clinical concern (Tomkin 1973 Bergman, Boman and Wilholm 1978). However, this should be borne in mind when prescribing for elderly subjects who have a relatively high incidence of atrophic gastritis and vitamin B12 deficiency. Although rare, the most dreaded side-effect is lactic acidosis, the incidence of which is approximately 9 per 100 000 persons per year in metformin users (Stang, Wysowski and Butler Jones 1999), almost 10 times lower than that associated with phenformin. Therefore, any clinical condition associated with or predisposing to lac-tate generation or decreased ability to clear lactate is a...

Dietary History

Eating disorders and in particular binge eating are common among the obese, with prevalence estimates of 23-46 in those seeking treatment (46). Binge eating disorder has also been reported to be associated with Type 2 diabetes, but would appear to precede Type 2 diabetes in most patients. The prevalence of binge eating disorder in those with Type 2 diabetes was recently estimated as 10 among a sample of 322 German patients (47). Other forms of disordered eating, including night eating syndrome, should also be considered when assessing an obese individual.

Dialysis Initiation

Dialysis guidelines from the National Kidney Foundation promote the early initiation of RRT for diabetic patients, due to an increased susceptibility to uraemic symptoms at lower serum creatinine levels than non-diabetic subjects (4). Early RRT for diabetic renal failure not only relieves the symptoms of nausea, anorexia and vomiting but also helps reduce overall mortality. However, despite these recommendations, dialysis is frequently delayed due to either personal resistance or inadequate dialysis resources.

Role Of Education

Most type 1 DM patients achieve, at best, only suboptimal control of blood glucose levels. Around 25 of adult type 1 diabetic patients exhibit persistent poor glycemic control. Lower socioeconomic status and psychologic factors including lack of motivation, emotional distress, depression and eating disorders have been associated with poor control. Clinical experience over decades and data from the Diabetes Control and Complications Trial (DCCT) emphasize the role of diabetic education in the attainment of good glycemic control. Constant teaching, encouragement and support of these patients combined with open access to diabetes specialist nurses (DSNs) are fundamental to this goal. Methods of improving glycemic control include strategies that facilitate self-management, such as motivational strategies, coping-orientated education and psychosocial therapies, and intensification of insulin injection therapy or CSII. One self-empowering intensive educational program called DAFNE (Dose...

Celiac disease

Clinical symptoms vary dramatically according to the individual and the age. Young children often present with diarrhea, abdominal pain, and poor growth, though vomiting, irritability, anorexia, and even constipation are common. Older children and adolescents sometimes present with short stature, neurological symptoms, and anemia (36). The classic presentation among adults is diarrhea, abdominal distention or discomfort though only about 50 of new cases in the last 10 years have presented with diarrhea (37). Many people have silent symptoms such as chronic anemia, osteoporosis, gastroesophageal reflux, unrecognized weight loss, and elevated liver enzymes. Erratic blood glucoses from untreated CD in individuals with type 1 diabetes are sometimes exacerbated by concomitant gastroparesis. Anorexia (poor appetite) Bloating


Finally, a number of gut hormones give feed back to appetite-controlling areas of the CNS in the regulation of meal size and frequency (287,288). Cholecystokinin (CCK), glucose-dependent insulino-tropic peptide, and glucagon-like peptide 1 regulate satiety as enterogastrons and incretins. They also directly affect the satiety centers. Therefore, these pep-tides may participate in the pathogenesis of eating disorders (289). In mouse brainstem nucleus tractus solitarius POMC neurons are activated by CCK and feeding-induced satiety and that activation of the neuronal MC4-R is required for CCK-induced suppression of feeding. Thus, the melanocortin system provides a potential substrate for integration of long-term adipostatic and short-term satiety signals (290). Hirschberg et al. evaluated CCK levels in a group of obese women with polycystic ovary syndrome. They observed that women with PCO syndrome have reduced postprandial CCK secretion and deranged appetite regulation associated with...


All sulphonylureas can cause allergic rashes, gastrointestinal disturbances (usually mild) such as anorexia, nausea, and vomiting, and, rarely, reduction in platelets, white cells, or aplastic anaemia. They can also cause flushing with alcohol although this is particularly pronounced with chlorpropamide. Weight gain may be a problem in some patients. Cholestatic jaundice (usually reversible) may occur with chlorpropamide and hepatic dysfunction may be caused by some sulphonylureas. Chlorpropamide also has an anti-diuretic hormone-like action and hyponatraemia is not uncommon, especially in people taking diuretics.

The Biguanides

Metformin vs placebo can lower total cholesterol by up to 5 , triglycerides by 16 , and low-density lipoprotein (LDL) by 8 , with modest increases in high-density lipoprotein (HDL) of 2-5 . These values are not significantly changed when used in combination with sulfonylureas. The major adverse effects of metformin are gastrointestinal, including abdominal bloating, cramping, diarrhea, anorexia, and nausea, being reported in 20-30 of patients. These adverse effects are usually mild and can occasionally be mitigated by taking the medication with food.

In This Chapter

Knowing how many kilocalories to consume Monitoring carbohydrates, glycemic index, and fiber Picking the best proteins and fats Getting enough vitamins, minerals, and water Understanding the dietary impact of alcohol Using sweeteners other than sugar Considering dietary needs of type 1 and type 2 diabetes Losing weight Dealing with eating disorders

Dysregulated Eating

Approximately 5 of women and 1 of men suffer from anorexia nervosa, bulimia nervosa, or binge eating disorder. An estimated 1 in 100 American women binges and purges to lose weight and 15 of young women have significantly disordered eating attitudes and behavior (56). Although eating disorders can strike anyone, the most common demographic affected is adolescent, Caucasian females, of middle to upper middle class socioeconomic status. At particular risk, however, may be people who modify their diet because of an illness such as diabetes or celiac disease (57) When considering the development, prevalence, and medical risks of dysregulated eating among adults with DM1, it is important to remember that most adults with DM1 are diagnosed as children or adolescents (58). For both women and men in the United States, adolescence constitutes the developmental period during which dieting, dysregulated eating, and eating disorders are most likely to develop (59,60). Therefore, a discussion of...


The excretion of some active drug metabolites and increases the risk of hypoglycaemia. Sulphonylureas with shorter biological actions, such as glicazide or the older tolbutamide (metabolised by the liver) are associated with less hypoglycaemia. Metformin is effective in obese older patients as it indirectly increases insulin sensitivity, promotes weight loss and is not associated with hypoglycaemia when given as monotherapy. Renal function should be monitored in patients taking metformin (71) and not used when renal impairment is present or if there is severe anorexia. Age should not be a barrier to starting insulin and is often required for elderly patients with Type 2 diabetes, who can usually cope well with the new insulin pen devices (68).