Four Ways to Spot Disordered Eating Behaviors in Diabetes Care

Disordered Eating Behaviors in Diabetes (DEB-D) is more common than many professionals realize. Research conducted in 2017 by Garcia-Mayer noted that as many as 20-40% of patients with type 2 diabetes present with disordered eating. This startling statistic caused me to reflect on what might be a red flag for DEB-D.

"My diabetes is improving because, WITHOUT TRYING, I am losing weight." While this comment might indicate diabetes out of control, it also can confuse the client who might think that any weight loss is good. Having a weight loss focus in diabetes care drives disordered eating behaviors.

"My loss of appetite is a good sign." Again, elevated blood sugar can depress appetite just as an improvement in overall A1C and medication may moderate hunger/fullness. Associating the change in appetite as beneficial is another example of how weight-centered care dominates a client’s perception of diabetes care. In this example, the individual is thinking that a loss of appetite, which could result in a decrease in nutrition, is beneficial. Additionally, as mentioned earlier, a decrease in appetite as the result of elevated blood sugar--a condition coined 'glucose toxicity'--is not helpful. This erroneous belief that eating less will be enough to improve their diabetes, may delay medical care or contribute to clinical inertia.

I was curious about the experiences of other professionals, so I reached out to the WN4DC professional group and asked, "How do you spot DEB-D?” This group identified four key behaviors which were red-flags for DEB-D, including villainizing food, weight, the fear of eating, and self-blame.

Villainizing Food (Carbohydrates).

  • Megan Muñoz, RN, MSN, CMSRN, CDCES, and creator of the Type 2 and You, with Meg podcast explained, "Someone told me after she had two blueberries, two tablespoons of full-fat yogurt, and one small square of her husband's cereal that, ‘My body is so sensitive to carbs. I used to be able to handle them, but now anything I eat will shoot my blood sugars up.’” Megan continued, "I hear this type of comment all the time." Why would this comment be a red flag for DEB-D? Clients are surprised, disappointed, and have an unrealistic expectation regarding blood sugar fluctuation when eating. Seeing blood sugars rise at all appears to be at the heart of the fear and, instead of learning more about diabetes and what causes blood sugar fluctuation, the client is now blaming themselves for eating or blaming their body for having blood sugar fluctuations.
  • Emily Opthof, RD, BScFN, shared the following red flags: “I can't eat XYZ because it's so bad." This classic example of villainizing food is part of the shame binge cycle.() In the shame-binge cycle, 'bad' foods are often eaten to comfort the client after experiencing an emotionally challenging experience. However, by eating 'bad food,’ the client is now burdened with guilt, which is internalized as them being 'bad.’ It isn't hard for the client to feel an increase in shame energizing shame and setting the client up to binge. If weight gain and/or an increase in blood sugar accompanies eating, this is often used as evidence to the client and the health care professional that the client is at fault.
  • "I stopped eating XYZ." In this example, we see the preoccupation with food increasing. For individuals with disordered eating, thoughts of food, eating, and weight begin to occupy more and more of their mental energy. In some cases, clients may actually dream of eating, causing the amount of time consumed by disordered eating to exceed 100%! Now, for someone with type 2 diabetes, this preoccupation is magnified by blood sugar, society's misunderstanding of diabetes, and standard diabetes care medical appointments, which often focus on weight and A1C and not on the psychological stress associated with the disease. Clients with DEB-D have experienced a double-sided burnout, one from disordered eating and the other from diabetes.


Weight.

  • "I absolutely need to lose weight, I'm desperate." "I would feel so much better if I could just be back at my college weight." Denise DelPrincipe MS, RDN, LD, identified, as a red flag, the statement, "I know my blood sugar will be better if I just lose weight." This, again, is suggesting that weight change, often achieved by engaging in extreme, unbalanced, restrictive eating, and exercise behaviors improves health is the hallmark of DEB-D.

Fear of Eating

  • Courtney G. Riedel, MS, RDN, LDN, identified the fear of eating such as, "Eating anything with carbs scares me," or "I'm so mad at food because I know it will hurt me," as being a red flag for DEB-D.


Self-blame.

  • Holly Paulsen RD, CEDRD-S, LD, explains that, over time, clients develop the habit of engaging in self-blame. They see their inability to maintain a level of preoccupation with food, restricting their intake, being hypervigilant with what, when, and how much they eat as a personal failure. They don't see these behaviors as physically, mentally, and emotionally sustainable. Holly explains, when I hear, "I know what to do, I just can't do it," I know there is more to unpack.

It is helpful to see that DEB-D, is gaining more awareness and that healthcare professionals are starting to identify key behaviors that impact both disordered eating and diabetes care. This article identifies four key thoughts, Villainizing Food, Weight, The Fear of Eating, and Self-blame and gives specific examples of how these thoughts might manifest. You can learn more about DEB-D by checking out the articles, resources, or courses including our news course Medication: The Missing Link in Weight Neutral Diabetes Care available at the Weight Neutral for Diabetes Care Symposium at www.wn4dcsymposium.com