August 20, 2008

Is Diabetes an Eating Disorder - Take Two

An alert reader commented that she had expected the previous post to be on a very different topic than the one it turned out to discuss. That's because we people with diabetes who care about our health are forced to develop what may look very much like obsessive behaviors to keep ourselves healthy.

So many people--including some doctors--believe that those of us who commit to getting normal blood sugars do it by developing an eating disorder.

The arguments for that interpretation are these: Like people with eating disorders we obsess over our food. We count the grams of carbohydrate in every serving. Some of us weigh our food on high tech scales. We measure our blood sugar after eating and if it isn't within range, we stop what we are doing and devote our entire attention to raising or lowering our blood sugar until it is. If our blood sugar is too high after a bout of careless eating, we may feel strong emotion--anger, fear, or self-condemnation for eating whatever it was that raised our blood sugar too high.

Superficially these behaviors do sound a lot like those of a person with an eating disorder. Except for one huge difference: An eating disorder is a behavior that makes our health worse. It is a dangerous behavior that, if it is not stopped, will lead to serious disability or even death. These outcomes are what first brought the major eating disorders, anorexia and bulimia, into the public consciousness thirty years ago.

But with diabetes, it is eating "normally" that leads to disability and death.

People with diabetes who embrace the idea that they have a "right" to eat like everyone else and who don't obsess about their food are likely to be running blood sugars many hundreds of mg/dls higher than normal for hours after each "normal" meal they eat. Over time those high blood sugars destroy their nerves, their retinas, their kidneys and their cardiac health.

People with diabetes who engage in the so-called "obsessive" behaviors described above, in contrast, maintain the normal blood sugars that provide them with normal health. Their A1cs are closer to 5% than to the 10% that is the typical A1c of most people with diabetes in America.

So you have to realize that what gets defined as "obsessional" has a lot to do with context. Is a person who washes their hands twenty-five times a day suffering from Obsessive Compulsive Disorder? Not if they are a physician whose work involves examining patients in a surgical unit. In that case, it would be a sign of significant mental illness not to wash hands before examining each new patient, because it has been proven through rigorous research that handwashing in the hospital is the single most powerful way of keeping patients from acquiring hospital borne infections.

I hope for a high level of "obsession" in the people who fly the jets I board and the people who work at my bank. If these people do not pay obsessive attention to details the rest of us might ignore, people will be harmed.

By the same token, the nutrient-counting behavior and restricted eating that might make us rightfully concerned when it is practiced by a thin 13 year old girl with no diagnosed health problems is cause for celebration in a 50 year old woman whose blood sugar rises to 300 mg/dl if she eats a single piece of cake.

If you are recently diagnosed with diabetes or if you have only recently started eating in a way that will normalize your blood sugars, be prepared to run into this issue with your family and friends, because when you begin to adopt the behaviors that are necessary to control blood sugar some of them may respond to these new behaviors with concern.

They may think it excessive for you to test your blood sugar once or even twice after a meals or before you start driving your car. They may feel uncomfortable if you interrogate a waitress about exactly what ingredients are going to be in a dish you are ordering, of if you have a fit when the diet soda you ordered turns out to be a sugary regular.

Instead of supporting you they may respond by telling you to ease up. Chances are they do this because to them these behaviors may look obsessive. Your friends and family care enough about you to want to protect you from developing a true mental disorder.

But in this case, their concern is misplaced. The people they should be worrying about are the people with diabetes who are eating "normally," who are not testing, who have no idea how much carbohydrate is in the portions of food they eat--people who are not doing anything but taking the inadequate drugs their doctors prescribe for them and who have no idea what their blood sugars are most of the time--people who have no idea what will happen to them if they don't keep their blood sugars beneath the level that causes complications.

So if someone close to you suggests, "Why not just forget all of that and just enjoy your dinner?" take it as an expression of love or concern. But then explain that you want to enjoy a lot more dinners--and that you enjoy your food best when you can see it and when you are able to walk away from the table on both feet. Let them know that the key to avoiding the most common diabetic complications is to keep blood sugar under 140 mg/dl at all times and even lower if possible.

Yes, it sucks that we people with diabetes have to pay so much attention to what we eat. All of us would love to be able to eat normally. But we can't. We got dealt this body and we have to live with it. We get no choice about that. The choice that is left to us is whether we want to just stay people with diabetes or if we want to become people with diabetic complications.

And if you choose to stay a person without diabetic complications, you need to put your eating into "order" and doing that requires giving unflagging attention to everything that you eat. To keep yourself healthy, in short, you must adopt intensive behaviors which have the opposite effect of harmful eating disorders.


Anonymous said...

absolutely right on.....great post!

Anonymous said...

Thanks for posting this. I recently had to travel to an unfamiliar city for business, and posted on the Chowhound forum to ask for recommendations, explaining my needs (high protein, low carb, no pizza or sandwiches, etc) - and instead of helpful answers, I got accused of "orthorexia."

Other responses included "It won't kill you to eat a sandwich once in a while."

All of this led me to conclude that some people are threatened when they see others with strong discipline. Instead of being seen as a positive thing, it's turned into something negative - OCD, or orthorexia, or an eating disorder.

Lili said...

So, so true. One of the greatest disappointments for me after diagnosis was getting this attitude...from my Type 1 friend. I had thought this person would be the most supportive, but instead they regularly tell me I'm "testing too much," that I'm "nuts," etc. I just find it very sad.

Scott S said...

I wrote to Amazon about their recommendation of books pertaining to eating disorders and diabetes, and they responded but I'm hoping they get enough comments to reconsider their erroneous recommendations!

Anonymous said...

LOL! I suppose all of us type 1s have eating disorders then. Many of us test as often as every hour. Don't type 2s deserve the same level of care?

Anonymous said...

Would that you could explain this as clearly to those "authorities" who believe "too much testing" is obsessive - and define too much as more than three times a week . . .

I just had an example of "not obsessive enough", I thought I was a bit wobbly considering the amount of wine I drank with my meal and had to cut short my walk round the village and go lie down. When I got up I found I'd taken an extra blood pressure pill instead of a famotidine . . . do not try this at home

ItsTheWooo said...

I agree in general Jenny but I do think it is possible for what was once originally healthful behavior to cross into obsessionality (and an eating disorder). Technically it is possible to become so consumed with one's health that further monitoring does no good, and only impinges upon enjoying life by harming mental health.

I agree most diabetics would be served to become MORE concerned about blood sugar control, not less. Sometimes it is possible to become too concerned with controlling an otherwise valid health problem. I wonder if the phenomenon of "diabulimia" has any relationship to the emphasis on food and weight control, which for certain vulnerable people may push them to irrational obsession?

Anne said...

I have gluten intolerance. In order to completely eliminate gluten from my diet, I have to be obsessive about my food. I have to read every label, call manufactorers and carefully question the people who serve me in a restaurant. If I don't do this I get sick. Many friends and family members roll their eyes as I check my foods.

Now add in a low carb element and frequent testing to keep my blood glucose under 120(OK, it does get to 140 at times) and you ought to see the eye rolling I get now.

I don't feel I have an eating disorder. I feel I have found a key to better health. Perhaps the people who eat the Standard American Diet have the eating disorder - eating foods that you know are bad for your health, but you eat them anyway.

If not a mother... said...

I think it is entirely possible to cross the line from excellent diabetes management to obsession. I've been there - only to see that it did my blood sugars no good at all.

Obsession about every single carb and regret over every missed exercise session only leads to stress, which is what we need the least as people with diabetes.

We all need to let go for a couple hours now and then, whether that means a couple glasses of wine or a dessert. That's not going to kill us, but constant stress can.

K. Dill said...

This might seem an odd question, but has there ever been a direct causal link between elevated glucose and complications, particularly vascular damage, or is it **just** correlated ? I ask due to a recent review by the cohrane group.

Jenny said...


There are a growing number of robust studies that show the prevalence of neuropathy, retinopathy and heart disease rising with both A1c and with post-meal glucose.

The confusion sets in because the ACCORD study which attempted to lower cardiovascular risk by lowering A1c did not achieve this. However, the problem with ACCORD was the drug/diet combination used to lower blood sugar. That study suggested that high carb diets which then require huge amounts of insulin or insulin-producing sulf drugs may not be good for cardiovascular health in people who already have heart disease.

A larger study, ADVANCE, did not confirm this study.

There is NO large scale study that tracks what happens to cardiac health when people lower A1c by cutting down dramatically on carbohydrates, using much lower doses of drugs.

Alan said...

Bravo Jenny. Once again you say it right and you say it well.

I was also told to "lighten up a bit" when I was testing a dozen times a day and querying waiters and chefs. Those tests back then were building the database that allows me to maintain good control now with just "maintenance" tests.

Anonymous said...

Thank you, Jenny--I appreciated this post, and I think there's a lot to think about here.

On the one hand, I'm very willing to do all the work my Type 1 diabetes requires in order to feel well, be productive, and try to avoid complications. But on the other hand, my mental health, my relationships and my life energy matter to me as much as my physical health. It's taken me a long time to find the line between diligence and obsessiveness and to decide for myself how much energy I can afford to spend monitoring my food and my health...and what I can maintain over time!

Also, I hope these are attainable goals: an emotionally healthy and pleasurable relationship with food, a body whose desires I can trust(a basic human quality I don't want to lose) and a clear understanding of the types and quantities of food that help me feel well. I'm trying my best to integrate my meter results and my insulin doses into my body's own wisdom--a work in progress after 30 years!

Effective diabetes management is not an eating disorder; but genuine eating disorders wreck your life and are an all too common side effect of diabetes. Dietary awareness and management for diabetes needs to be taught (by CDE's and by us helping each other!) in an intelligent and empowering way so that the whole person--BGs, weight, energy, emotions, and mind--stays as healthy as possible.