Approximately 1.25 million American children and adults have type 1 diabetes (T1DM), according to the American Diabetes Association. Type 1 diabetes is an autoimmune process whereby the insulin-producing cells of the pancreas are irreversibly destroyed and the ability to use food as energy is impaired. It can lead to growth stunting, intellectual impairment, blindness, vomiting, poor circulation and even limb amputation. It is not the kind of diabetes that you read about in the press as being the result of “lifestyle choices.”  

Prior to the invention of insulin shots, T1DM was uniformly lethal. And while today we can control it, we still have no cure.

There have been many medical advances in the treatment of T1DM, but the dream of an artificial pancreas has not  been realized, and until it is, diabetics are forced to use insulin injections and their conscious decisions about food as a substitute for the kind of unconscious glucose control we all take for granted. You can imagine how often this can go wrong, even with the best of intentions!  

The balance between insulin and glucose is part of a well choreographed dance between our pancreas, liver, gut, brain and muscles. It is how we make energy out of the food we eat, how we control our growth and muscular strength, and when it goes awry, it affects everything. Uncontrolled, untreated diabetes leads to delirium, coma and death. Over-controlled diabetes can lead to blood sugar lows that are at least as dangerous. Steering between this Scylla and Charybdis, is it any wonder that the added complication of eating disordered behaviors can be overwhelming? No one asks to have T1DM, nor is it caused by parents or “lifestyle choices,” in fact, it’s not a “choice” at all -- sound familiar?

So how can eating disorders complicate the treatment of diabetes?

  • Restricting food intake can magnify low blood sugars
  • Unpredictable bingeing overloads planned insulin injections
  • Unpredictable, though normal, food intake can cause dangerous hypo or hyperglycemia when there is a mismatch between insulin given by needle and food taken in
  • Continual disruptions in blood sugar control can lead to poor vision, destroy the peripheral nervous system and affect mood and behavior
  • The temptation to induce rapid weight loss can lead to a patient’s intentional underdosing of their insulin
  • Purging can cause electrolyte disturbances (such as low potassium) which are then worsened by the administration of insulin and lead to sudden death

At Kartini Clinic we have treated many children with co-occurring diabetes and eating disorders. It is not actually hard for a treatment program with a strong medical team (i.e. one that is always onsite, not simply using “consulting” physicians), but the fact that close adherence to first principles (see below) sometimes flies in the face of a child’s desire for autonomy can make it challenging. Getting parents on board with first principles from the start is critical.

What are these first principles at the beginning of treatment?

  • Parents must be in charge of all food and willing to record it (no different than for any patient with an eating disorder)
  • Parents must be in charge of glucose measurements (this is made easy by contemporary glucometer devices which store multiple measurements)
  • Parents must be in charge of supervising insulin administration and willing to record it
  • In the partial hospital or intensive outpatient setting, staff must be trained in supervision of meals AND insulin injection
  • Staff must be trained in emergency administration of glucose or glucagon
  • Every effort must be made to empower families to become experts in management
  • Staff must be able to communicate swiftly and easily with the child’s diabetologist

Our experience has been that close adherence to these first principles gives our diabetic kids with eating disorders great blood sugar results-- sometimes for the first time in years. Their blood sugar is better, their energy improves and their mood is better. Then we can work on the eating disorder.

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