Feature

disordered eating and type 2 diabetes

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It is becoming increasingly apparent that eating disorders may occur within the context of type 2 diabetes and this may complicate the management of the condition. Dr Shaine Mehta1, Samina Hassan2 and Professor Khalida Ismail3 (right) explain how psychological therapy may help unravel disordered eating patterns in type 2 and present a case history that illustrates this approach

oth diabetes and eating problems have a focus on diet control and weight management, and there is

growing understanding that in type 2 diabetes, there can be an overlap with disordered eating (disordered eating behaviour and diagnosed eating disorders)1. Patients may use the condition to mask the disorder, and omission of hypoglycaemic medications can be a feature. Not taking medication as recommended results in poor glycaemic management and therefore increases the risk of complications from diabetes.

Risk factors include body image concerns, female gender, greater body weight and a history of depression. Missed appointments, low self-esteem, high levels of diabetes distress and poor

1 NIHR In-Practice Fellow, King’s College London & Diabetes Clinical Lead, City & Hackney CCG

2 Specialist Psychological Therapist in Diabetes, Hackney Diabetes Centre, Homerton University Hospital

3 Professor of Psychiatry & Medicine, King’s College London

suboptimal glycaemic management should all raise suspicion of eating problems2.

Eating problems and type 2 diabetesThe link between type 2 diabetes and obesity is well established – however, the link with eating disorders is less explored. Recent studies have shown an increased prevalence of binge eating disorders in patients with pre-existing type 2 diabetes3. As the prevalence of type 2 diabetes continues to rise, recognition and treatment of eating disorders in this group will be crucial to optimise support4.

Furthermore, as treatments for type 2 diabetes increasingly include newer agents that affect satiety, such as

GLP1-agonists, as well as interventions like bariatric surgery and very-low-calorie diets, screening patients for eating problems is even more pertinent, as this may adversely affect the outcome3.

The different patterns of disordered eating in type 2 diabetes have not been extensively studied. Some might reflect patterns observed in the general population, such as large portions, grazing, comfort eating and binge eating in the context of emotional distress. But as focusing on food is key to diabetes management, with so much attention on what to eat, over time this can lead to problems with how people feel about food and themselves. Other patterns might reflect a response to fear of hypoglycaemia, and misuse of insulin treatment for weight management. Brief

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DIABETES PSYCHOLOGY

The complexity of the link between physical and mental health suggests that this group would benefit from specialist mental health teams, consisting of psychiatrists and psychotherapists who have expertise in diabetes being integrated into the diabetes team

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questionnaires, such as SCOFF, may be used for screening, but have not been extensively tested in type 2 diabetes5.

There is some evidence that psychological support can help facilitate self-management in type 2 diabetes6. The complexity of the link between physical and mental health suggests that this group would benefit from having specialist mental health teams, integrated into the diabetes team. Programmes, such as Integrating Mental and Physical Health Research, could help with screening and first-line management7. Many people are also suffering from depression and closer working with Improving Access to Psychological Therapies for Long Term Conditions may facilitate earlier screening and support8.

Living with diabetes places a spotlight on eating behaviours in many ways, including through self-monitoring, insulin dose adjustment or management of hypoglycaemia. This occurs both on an individual level and through input from others – for example, healthcare professionals or opinions of family members. Many people living with diabetes manage this adjustment well.

However, for some people the relationship can be more complex for several reasons. Managing diabetes can bring to the surface unhelpful patterns of coping or even increase disordered eating patterns, as individuals push themselves towards a healthy weight or optimal blood glucose management. As a psychological therapist, my role involves working holistically with individuals to support them to understand their relationship with diabetes and the various factors which may be impacting this. When it comes to understanding eating behaviours, through assessment, we explore the nature of the problem, the function of eating behaviours, how they have developed over time and what factors increase or reduce these behaviours.

In my work, I often find that disordered eating behaviours can be tied to the relationship a person has with themselves, their ability to regulate or make sense of difficult emotions and the use of food as a protective strategy to self-soothe or even punish themselves.

Through formulation, together we can build up a shared understanding of their difficulties and how we might start working towards addressing these. The therapy itself focuses on changing unhelpful behaviours through strategies aimed at introducing routine, exploring the benefits of planning, the use of behavioural experiments to test out unhelpful predictions and identifying alternatives to bingeing or purging behaviours. Compassion-focused techniques may be used to support an individual to turn towards their distress and tolerate the discomfort that comes with difficult emotions. Together with a caring motivation towards self-care, the therapy supports the individual to address unhelpful thinking patterns, strengthen their compassionate voice and explore blocks to giving or receiving compassion. This can be done through imagery techniques, compassionate letter writing and thought challenging among others.

Over the page is a sample of a letter a patient living with diabetes wrote during therapy, talking back to the critical part of herself that was responsible for some of the restrictive behaviours she found herself engaging in at the time.

In summary, psychological therapy provides the means to voice the hidden parts of the self that may sit beneath diabetes-related distress or disordered eating; facilitating access to further engagement and change.

Perspectives from a diabetes psychological therapist and patient

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DIABETES PSYCHOLOGY

References1 American Diabetes Association, Types of Eating

Disorders. www.diabetes.org/diabetes/

mental-health/eating-disorders

2 Diabetes UK. Emotional health professionals

guide. Chapter 8 -Eating Problems.

www.diabetes.org.uk/up-eating-problems

3 Abbott S, Dindol, N, Tahrani A et al (2018).

Binge eating disorder and night eating

syndrome in adults with type 2 diabetes: a

systematic review. Journal of Eating Disorders

Nov 6, 6(36)

4 Shaw J, Sicree R, and Zimmet P, (2010). Global

estimates of the prevalence of diabetes for

2010 and 2030. Diabetes Research and

Clinical Practice 87(1), 4–14

5 Morgan J, Reid F, and Lacey J (1999). The

SCOFF questionnaire: assessment of a new

screening tool for eating disorders. BMJ

319(7223), 1467–1468

6 Ismail K, Winkley K, and Rabe-Hesketh S

(2004). Systematic review and meta-analysis of

randomised controlled trials of psychological

interventions to improve glycaemic control in

patients with type 2 diabetes. The Lancet

363(9421), 1589–1597

7 King’s Health Partners. Integrating Mental and

Physical Health Research: Delivering integrated

care for better wellbeing.

www kingshealthpartners.org/resources/

case-studies/754-imparts-delivering-

integrated-care-for-better-wellbeing

8 NHS England. Improving Access to

Psychological Therapies for Patients with

Long-term Physical Health Conditions and

Medically Unexplained Symptoms. www.

england.nhs.uk/wp-content/uploads/2018/03/

improving-access-to-psychological-therapies-

long-term-conditions-pathway.pdf

‘Dear Strict Controller,

I am writing this letter to you, to try and take some control back. I feel that I have been too passive in letting my control go and not letting myself assert what I actually want and need. This might not be the right approach, putting blame on myself. But I would like to learn from it and start to take back some ownership. Now feels like a time for me to feel more empowered by myself.

I tried to take control of things when I realised that the stakes were high in terms of complications. But, Strict Controller, you turned a blind eye to the other side of the coin. The low blood sugars, feeling vulnerable, feeling washed out, feeling stupid and exhausted and just not myself at all. Like a faded person half there and only half existing.

You turned away, but why? Maybe you were scared too. Maybe you wanted to inflict punishment on me, make me feel guilty for all those years as a teenager and younger adult when I just let things run riot – going out partying, drinking… turning into something all mixed up with eating problems, and feeling depressed, and anxious. Now I see I was coping with stress, at home, in myself. But you made me feel like I had put myself in harm, I was careless and reckless and should let myself be strictly controlled by you.

And slowly it worked, you let it become normal. So normal I didn’t notice that it seeped in and started to take over my life. A little bit too much insulin here, and there. Rounding up, never down. Creating reasons to eat more – knowing I craved rewards or sensory pleasure, emotional eating. Not really what I wanted but it all became so blurry. The more lows I had, the more my appetite was totally ruined. Desperately craving something, but never quite hungry. Always a bit sick, always a bit empty. And you made me vulnerable. I had a seizure. I grew more and more anxious. At work, out with friends, on my bike, wherever. You took away my confidence, and my happiness.

Strict Controller, your favourite game is to darken a sunny day. A day out to the beach or a relaxing evening. You were always there to cast shadows and insecurity and doubt. Just when I least want it, when it is supposed to be a happy or relaxing time. Never quite able to relax in the moment, always a second eye on the numbers, the perpetual nervousness that I was dropping… then rising… then falling… the sky lining. You let me have no peace! No break.

And now Strict Controller, my foe, I am beginning to see your game. To see how you crept in and took root and I was naive and didn’t see it happening and earnestly believed it was for the best. But now I am sensing what life is like beyond you – I’m starting to outgrow you.

Strict Controller, my friend, you have taught me lots about myself. But now it is my time and the peace of mind I get snatches of as I let you go, as I let myself be, let me walk down the street with my head held higher.’

In summaryEating problems in patients with diabetes can result in a complex interplay between physical and mental health. Awareness of the increased prevalence of eating problems in type 2 diabetes is important for optimising glycaemic management and improving patient wellbeing. The growth in prevalence of patients with type 2 diabetes presents a priority area for awareness and screening for this important issue.

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