Ginger E. Nicol, MD
McCallum Place St. Louis
Binge eating without compensatory purging may be the most common type of disordered eating in Type 1 Diabetes.1 But medical providers, parents and loved ones often don’t think to look for it. Type 1’s who binge eat have chronically higher blood sugars, higher weight, are more likely to experience diabetes complications like retinopathy, and may be at risk for developing “brittle” diabetes – wide swings of blood sugars from high to low associated with mood instability, irritability and fatigue. Most people with Type 1 don’t start off with disordered eating. Although there is little research on the topic, there are probably multiple factors that lead to the onset of binge eating in this population. The good news is that binge eating can be prevented, and also treated – if you know what to look for.
Potential Causes of Binge Eating in Type 1: Psychology & Biology
Psychologically, Type 1 Diabetes requires a constant focus on eating, insulin dosing and blood sugar monitoring. Although the current recommendations are to encourage flexible eating (e.g. allowing some desert or high-carb foods and dosing insulin appropriately), this still feels restrictive to many people because it requires some degree of planning. Additionally, many with Type 1 only allow themselves these sorts of foods when they are treating a low. This is a setup for feeling deprived, while alternatively being rewarded by lows and risking a rebound high from overdoing it.2 Many people notice that after starting on insulin – commonly after several weeks in a state of ketosis and resultant weight loss – there is a notable weight gain, sometimes past that of the normal baseline weight. This may be distressing to many and lead to abnormal shape and weight concerns, especially in girls.
Biologically, the treatment for Type 1, insulin, is an anabolic hormone which helps to store energy as living tissue in our bodies. Excessive exogenous insulin leads to hypoglycemia. Since our brains can only run on sugar, our bodies have developed some pretty dramatic ways to deal with low blood glucose. Counter-regulatory hormones like glucagon and epinephrine are secreted, and the nervous system kicks in with a bang to tell you to EAT. The rule of “15s” – eat 15 grams of carbohydrate and wait 15 minutes—is what most diabetes providers recommend when treating a low. The problem is that blood sugars may lag behind eating by about 15 minutes or so, but your hormones and nervous system don’t know that – together they drive eating until the symptoms resolve. This can contribute to “rebound” hyperglycemia, which may last a few hours while the nervous system and counter-regulatory hormone responses to a low slowly resolve. When hyperglycemic, body tissues are starved for energy because there isn’t enough insulin to move glucose into cells for processing and storage. This can lead to fatigue and hunger, increased food intake and higher insulin doses with resultant hypoglycemia. And then the binge cycle starts all over again.
Risk Factors for Binge Eating in Type 1: Stopping the Cycle Before it Starts
Young girls and women, especially those who have poor body image, depression, anxiety or problems with impulse control prior to being diagnosed, are most likely to engage in disordered eating.3 It’s important for providers to assess for and treat these conditions as insulin therapy is being started. Loved ones and parents can be helpful by learning about flexible eating and insulin dosing, e.g. matching insulin dose to carbohydrate intake. This is known to improve quality of life, problem-solving skills and Hgb A1c in Type 1 Diabetes.4 Providers and parents can be regulated in the face of highs or lows, demonstrating and reinforcing a calm and measured response to both. And practicing radical acceptance is important for everyone in the equation: being healthy is about living with diabetes, and accepting you will sometimes make mistakes. A high or a low is almost always traceable back to a defined event or situation – whether it’s eating-related, insulin dose-related, or stress-related—carefully and non-judgmentally considering these while making adjustments for the future is critical. The only true mistakes in life are the ones we don’t learn from.
Assessment & Treatment of Binge Eating Disorder in Type 1
• Start by looking for clues: High daily insulin doses and wide swings in blood sugar, extreme hypoglycemic reactions and compensatory binges in response to lows, irritability and fatigue, weight gain.
• Ask about relationship to food in a compassionate way: Remember that the nature of the illness itself necessitates an atypical perception of food and nutrition. Specifically ask about urges to binge and whether there are feelings of loss of control while eating. Validate and educate on the biological and psychological reasons for binges.
• Consult with a dietitian: A dietitian, especially one with eating disorder expertise, can be invaluable in working with patients who are binging or are at risk for binging. One of the first steps is to assess whether binges are occurring due to hunger or feeling deprived, and then problem solving to establish an intuitive eating plan that allows for foods that are satisfying but that don’t require a high insulin dose to cover.
• Normalize blood sugar excursions: Encourage insulin dosing prior to eating (up to 30 minutes before, depending on what type of insulin is used), or switch to a quicker-acting insulin like inhaled insulin to avoid post-prandial highs. Assess whether correction doses are appropriate – too high leads to lows and potential binges; too low leads to high blood sugars and potential insulin stacking, or sequential doses to bring down a high that can result in a low later. Aim to gradually decrease total daily insulin dose to minimize the appetitive drive associated with high insulin and high blood sugar.
• Consider medical and psychological treatments: High dose serotonin reuptake inhibitors (SSRI’s) like fluoxetine (Prozac), and stimulants like lisdexamfetamine (Vyvanse) can decrease binge urges and binge episodes. Cognitive Behavioral and Interpersonal therapies (CBT and IPT) have demonstrated effectiveness in decreasing binge episodes. But they can also help people live with and manage their diabetes better by addressing cognitive distortions, developing better coping and emotion regulation strategies, identifying interpersonal roles and transitions that impact health behaviors, and shoring up natural social supports.
References
1. Scheuing N, Bartus B, Berger G, et al. Clinical characteristics and outcome of 467 patients with a clinically recognized eating disorder identified among 52,215 patients with type 1 diabetes: a multicenter german/austrian study. Diabetes Care. 2014;37(6):1581-1589.
2. Merwin RM, Moskovich AA, Dmitrieva NO, et al. Disinhibited eating and weight-related insulin mismanagement among individuals with type 1 diabetes. Appetite. 2014;81:123-130.
3. Olmsted MP, Colton PA, Daneman D, Rydall AC, Rodin GM. Prediction of the onset of disturbed eating behavior in adolescent girls with type 1 diabetes. Diabetes Care. 2008;31(10):1978-1982.
4. Lowe J, Linjawi S, Mensch M, James K, Attia J. Flexible eating and flexible insulin dosing in patients with diabetes: Results of an intensive self-management course. Diabetes Res Clin Pract. 2008;80(3):439-443.
