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Binge Eating Disorder and Diabetes

Written by: Katrina Larsen, MS, RD, CDCES

In honor of National Eating Disorders Awareness Week (February 24-March 1), we want to draw attention to the complex challenges that occur when your patient with diabetes also has an eating disorder. We will specifically focus on binge eating disorder (BED) because it is the most common eating disorder. Have you had a patient with BED?

Eating Disorder: An Umbrella Term

When a person is diagnosed with an eating disorder, it’s important to understand exactly which eating disorder he or she has. In much the same way the word “cancer” describes a general condition while the specific type of cancer indicates presentation and informs treatment decisions, the phrase “eating disorder” refers to a general class of psychiatric illnesses. Each type of eating disorder presents in different ways and may require its own specific treatment(s). When you combine any eating disorder with diabetes, treatment for either condition becomes more complex.

Eating Disorders: How Common Are They?

Some common eating disorders include anorexia nervosa, bulimia nervosa, and binge eating disorder. According to a 2007 article in Biological Psychiatry, it’s estimated that 1.0% of US adults will experience bulimia nervosa, and 0.6% of adults will experience anorexia nervosa.¹ However, the rates of binge eating disorder are much higher. A 2011 article in Archives of General Psychiatry states that binge eating disorder (BED) affects 3.5% of women and 2% of men in the U.S.² 1.6% of adolescents are also affected by BED.² However, diagnostic criteria for BED was not officially listed in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition until 2013. This means that the condition may have been under diagnosed or under reported for the article from 2011. It’s possible that actual prevalence is higher.

Add the trend for increasing rates of diabetes to the number of Americans affected by BED, and it becomes inevitable that we’ll see more and more patients presenting with these conditions simultaneously. So how can we identify these patients and tailor our treatment to help them manage their diabetes successfully?

How can I identify BED in my patients?

First, it’s important to recognize that BED is a psychiatric illness that should be evaluated and diagnosed by a primary care provider or psychiatric provider. However, it is possible that some patients may not disclose this diagnosis to you as a diabetes specialist. It’s also possible that you may have patients that have never been officially diagnosed with BED or may not realize they have a disorder, yet you may recognize symptoms of the condition. If you identify some of the following key diagnostic features³ of BED in your patients, consider asking about previous eating disorder diagnoses or referring them for a thorough evaluation from a qualified provider:

1. Recurrent and persistent episodes of binge eating
   • Eating, in a discrete period of time (e.g., within any 2-hour period), an amount of food that is definitely larger than most people would eat in a similar period of time under similar circumstances
   • The sense of lack of control over eating during the episode (e.g., a feeling that one cannot stop eating or control what or how much one is eating)
2. Binge eating episodes are associated with three (or more) of the following
   • Eating much more rapidly than normal
   • Eating until feeling uncomfortably full
   • Eating large amounts of food when not feeling physically hungry
   • Eating alone because of being embarrassed by how much one is eating
   • Feeling disgusted with oneself, depressed, or very guilty after overeating
3. Marked distress regarding binge eating
4. Absence of regular compensatory behaviors (purging, over exercising, etc)

If you suspect any of these symptoms in your patient, you may simply ask, “Have you ever been diagnosed with an eating disorder?” This can open a candid discussion about eating behaviors and also give your patient hope that he or she can get help.

How does BED affect diabetes care?

Because BED includes recurrent sessions of eating large amounts of food, this condition can complicate diabetes management. Here are just a few examples of how diabetes management may be affected by BED:

• Food intake may be under-reported
• Restricting carbohydrate foods may lead to more binge episodes with the “forbidden” foods, which can affect BG management
• Your patient may avoid testing or reporting BG following a binge
• Night binge eating may lead to persistently high fasting BG
• Your patient may withhold insulin on purpose to prevent weight gain from consistent overeating
• BG patterns on a CGM report may seem inconsistent with food logs
• Your patient may self-adjust insulin or other medications without reporting it to you
• Your patient’s BG patterns or Hgb A1C don’t seem to improve despite medication adjustments and dietary changes
• Your patient with a pump may use extra insulin for compensation and therefore require more frequent set changes
• Efforts to improve lipid profiles may be sabotaged by BED behaviors

How can I best help my patients who have been diagnosed with BED?

The first step to treating diabetes in someone with BED is to make sure they are also getting treatment for BED. It is important to recognize that a patient with active BED will simply not be able to manage his or her diabetes as successfully as someone in recovery or without BED. Here are some suggestions for treating a person with diabetes who also has BED:

1. Make sure your patient is also receiving treatment for BED from qualified providers. At the minimum, a therapist and registered dietitian who specialize in treating eating disorders are recommended.
2. Make BED behaviors a natural part of your discussions about diabetes management. Explain you need to know about their BED behaviors so you can help treat their diabetes in the best way possible.
3. Remove the shame around food choices. There is no need for “confession,” simply an honest discussion about your patient’s behaviors and challenges. Reassure your patient that you are not judging them. Approach the behaviors with compassion and express optimism that your patient will make progress in recovery.
4. Ask direct questions, such as
   1. Have you had any binge eating episodes since we last met?
   2. How is your BED affecting your diabetes care?
   3. Are you still seeing your therapist/dietitian to help with BED?
   4. Did you intentionally skip any BG tests in the past few weeks? Why?
   5. Have you had any victories regarding BED management or diabetes management in the past few weeks? Tell me what has gone well.
5. If appropriate, communicate with your patient’s therapist and dietitian for a unified treatment approach. Patients receiving care from a team are more likely to make progress toward recovery, which ultimately leads to better diabetes management.
6. Work to make food as neutral as possible and liberalize your patient’s diet as much as is possible or reasonable to prevent feelings of restriction during treatment for BED. Encourage additive diet choices to support diabetes care, such as adding more vegetables or adding more fiber. Once your patient is better managing BED, additional diet changes may be possible.
7. Educate yourself on eating disorders so you can better understand what your patient is experiencing and how it affects them trying to manage their diabetes.

The Big Picture

We know that as we treat a person with diabetes, we are not simply treating diabetes. Cultural choices, lifestyle factors, mental health status, and more are all part of the big picture that affects diabetes treatment. Learning more about specific mental health conditions, such as BED, can help us become more effective clinicians for our patients.

Trusted Resources for More Information:

National Eating Disorder Association

www.nationaleatingdisorders.org

National Institute of Mental Health

https://www.nimh.nih.gov/health/topics/eating-disorders/index.shtml

American Diabetes Association

https://www.diabetes.org/diabetes/mental-health/eating-disorders

Eating Recovery Center

https://www.eatingrecoverycenter.com/professionals/resources

References

1. Hudson JI, Hiripi E, Pope HG Jr, Kessler RC. The prevalence and correlates of eating disorders in the National Comorbidity Survey Replication. Biol Psychiatry.2007 Feb 1;61(3):348-58. 
2. Swansons SA, Crow SJ, Le Grange D,Swendsen J, Merikangas KR. Prevalence and correlates ofeating disorders in adolescents. Results from the national comorbidity survey replication adolescent supplement. Archives of General Psychiatry, 2011;68(7):714-723
3. American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders: Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Arlington, VA: American Psychiatric Association, 2013

Photo by Sharon McCutcheon on Unsplash