Children and adolescents with diabetes are under constant watch when it comes to what they eat. How can parents maintain a healthy diet in their children? Must they be on constant alert for eating disorders?

Do children and adolescents with diabetes really suffer more frequently from eating disorders? This is a question we therapists are often asked. In the day-to-day life with diabetes, one tends to be more aware of what goes onto the table, and children learn earlier about the different food elements than perhaps their non-diabetic counterparts. Families with a diabetic member tend to talk about food more. But does all this lead to an increased incidence of eating disorders in people with diabetes?

Medical research has shown that, indeed, there is an increased incidence of eating disorders not otherwise specified (EDNOS) in people with diabetes. This can easily be explained by the increased attention given to food and body. In most cases, these mild disorders rectify themselves and need no further treatment.

Hunger–food–hunger
In actual fact, the relationship between hunger and food is very simple. We get hungry, we eat, we feel satisfied for a good three to four hours, we get hungry again, and we eat again until satisfied, etc. However, in daily life, this routine is faced with many interruptions.

An innocent chocolate bar tempts one to eat between meals without hunger, causing us not to feel hungry when we are supposed to. We then eat less substantially at the next meal. As a result, the hunger sets in sooner. We then easily succumb to that chocolate bar again—or two—until we fail to feel any hunger at all. By the time dinner comes around we eat nothing. In this way, our inner bodily clock falls out of kilter. No longer does hunger determine our eating routine, but appetite and external temptation.

We also tend to eat out of boredom, unconsciously in front of the television, out of frustration, or socially. Our weight gets out of control. A glance in the mirror or at the figures on the scales tell us to lose weight. Children and adolescents tend to think that the easiest way to achieve this is to go hungry for a while. “I will simply eat nothing—or nearly nothing—for breakfast, and do the same for lunch.”

Real hunger sets in at school, causing them to think less about their school work and more about the baker shop on the corner. The regular lunchtime menu will often be skipped. By the time the evening meal comes around, the hunger is extreme and, before you know it, three meals are eaten instead of just one.

Eating to meet basic needs
Eating together around the table is pleasurable and has a lot to do with comfort and good living. It is a basic human need. Here is where the happenings of the day are expressed. Meals should be free of distractions such as televisions or mobile telephones. In this way, it is easier to make an appropriate association between hunger, appetite and satisfaction.  

Disinterest in eating
In many families, diabetes always accompanies the mealtimes. Everyone is very aware of what and how much goes on the table. The amount of carbohydrates can become a central theme. Everyone watches carefully what the kid with diabetes is eating! Eating at leisure becomes almost impossible.

Each bite has to be exactly planned for. This all tends to kill any natural desire for food, and leaves no room for eating intuitively or spontaneously. Everybody wants to have their say—especially the mother. Children with diabetes not only have the mirror to discourage them, but also their blood sugar readings.

How to restore interest
Fortunately, the outlook is not so grim. If the family cares to follow a few rules, disinterest in eating, or even EDNOS can usually be remedied without further ado. For example, calculating exchanges can be done in an uncomplicated fashion. Above all, the enjoyment of food—as well as for cooking—should be restored. This encourages healthy eating habits.

Snacking should be done as infrequently as possible, as our bodies should become used to having regular periods of non-consumption. High and low blood sugar readings should be seen as learning opportunities (“Why did this happen? What can be done to avoid this?”). These discussions should emphasize the positive elements in learning, and make it easier to manage the next time round. High/low readings should not be cause undue stress, but should be seen as building blocks towards learning and for changing what needs to be changed.

The glance in the mirror
One should not place too much emphasis on the image in the mirror. During puberty, the time in which body transformation is at its highest, adolescents spend much time in front of the mirror studying their appearance.

If the child continues to lose weight and fails to see this in the mirror or even, despite all reasoning, sees herself as getting fatter and fatter, the alarm signals should ring. She wants to keep losing weight, in spite of all objective advice to the contrary. The thinner she gets, the fatter she sees herself. She keeps reducing.

If the child has diabetes, she knows very well from her courses how easy it is to lose calories via the kidneys through using less insulin. Paediatric psychiatrists would say she is showing early signs of anorexia nervosa, whereby the desire to lose weight and to keep losing weight fixes itself in the mind, despite being underweight. Weight loss becomes an obsession.   

Early intervention
If it is obvious that she can no longer stop losing weight on her own accord, she needs professional help and vigorous therapeutical measures. It is well known today that anorexia nervosa can be treated more easily and effectively at the beginning of the disorder, whereby the weight loss is not already extreme, and if the patient is older at onset of illness.

Only 1.5% of all girls succumb to anorexia nervosa. This figure is no higher in girls with diabetes! If a girl with diabetes does fall ill, the diabetes therapy must be closely observed.

Bulimia
Losing weight can also be achieved by vomiting up any food that has been consumed. If one chooses to lose weight in this fashion, it usually ends tragically. Normally, our inner clock tells us that we are satisfied for up to four hours following a good meal. If an individual purposely vomits the meal up, the hunger that follows is extreme.

If one does manage to go without food for a lengthy amount of time thereafter, the inner bodily clock tells us that we have to eat much more for our next meal as the amount last time didn’t seem to be enough! This causes gorging which, in turn, leads to a repeated bout of vomiting due to a guilty conscience. A disastrous vicious circle sets in. Stomach acids damage the food pipe as well as the teeth. Loss of potassium threatens heart function.

The medical term for this illness is bulimia. The grey area between anorexia nervosa and bulimia is called bulimarexia. Bulimia must also be treated as early as possible, especially in people with diabetes. Early intervention with professional help from, for instance, the paediatric psychiatrist is crucial.

Building foundations
Eating around the table should be an enjoyable time for the family to eat together at regular intervals. This forms the basis for good eating habits. If you, as parents, detect an eating disorder (irregular eating habits, distorted body image, vomiting following eating, nocturnal gorging), the help of a paediatric psychiatrist should be sought as soon as possible.

As children and adolescents with diabetes are under supervision by their diabetologists, any eating disorders they may have are usually detected earlier than their non-diabetic peers. Therefore, treatment success is more likely.
Anorexia and bulimia represent two psychiatric conditions that require treatment from experts. Diabetes does not present a higher risk for these illnesses!

If, however, diabetes and a manifest eating disorder happen to collide, the paediatric psychiatrist and diabetologist must work closely together.

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Dr Dörte Hilgard (expert on diabetes) and
Dr Michael Meusers (pediatric psychiatrist)
Gemeinschaftskrankenhaus Herdecke
e-mail: doerte.hilgard(at)t-online(dot)de