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, including manipulation of insulin dosage to control weight, can severely compromise diabetes self-care, glycaemic control and medical management. A relationship has been reported between eating problems (especially bulimia) and poor adherence

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to non-diet aspects of the diabetes regimen , , poor glycaemic control , and complications77,78. Even subclinical disorders can interfere with glycae-

mic control. Several researchers found that insulin manipulation per se was associated with an increased risk for poor metabolic control80 and micro-

vascular complications48,78,81,82. Hepertz and colleagues49, on the other hand, found that in the German population they studied neither the presence of eating disorders nor insulin omission-influenced glycaemic control.

Eating disorders in people with diabetes are often unrecognized and untreated. As previously noted, differentiating between normal concerns with food and body image and pathological ones can be difficult in patients with diabetes. Those suffering from eating disorders are often resistant to acknowledging the problem. For many of these patients controlling eating feels crucially important, and they are terrified at the prospect of giving up this control, which they feel they will be pressured to do if they acknowledge their disorder. For these reasons, the health care provider must be alert to signs that a patient may be suffering from an eating disorder, especially when the patient is a young woman. These signs include frequent diabetic ketoacidosis (DKA), elevated glycohaemoglobin levels in a knowledgeable patient, anxiety about or avoidance of being weighed, frequent and severe hypoglycaemia, bingeing with alcohol, or severe stress in the family.

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