You Can’t See Disordered Eating

Identifying disordered eating isn’t as simple as asking if a person ate this or didn’t eat that. Identifying disordered eating requires us to look at both the motivation, fears, and behaviors surrounding food. The followig examples of eating disorder screening questions will give you a sense of how disordered eating is identified.  These questions were taken from the mScoff, EDE-Q, QEWP-5 screen tools. 

  • On how many of these times did you have a sense of having lost control over your eating (at the time that you were eating)?
  • Have you had a definite fear of losing control overeating? 
  • Over the past 28 days, how many times have you eaten what other people would regard as an unusually large amount of food (given the circumstances)?
  • Have you been deliberately trying to limit the amount of food you eat to influence your shape or weight (whether or not you have succeeded)?
  • Would you say that food dominates your life?
  • Have you eaten until feeling uncomfortably full?
  • Have you eaten large amounts of food when not feeling physically hungry?
  • Are you feeling disgusted with yourself, depressed, or very guilty after overeating?

“I’m Fine.”

While nutrition is the cornerstone of health, food can’t cure everything, and that includes diabetes. This fact is often assumed to be ‘false’ by the ever-increasing before and after photos that flash by in ads and on social media feeds explaining how someone ‘cured’ their diabetes. The accolades, praise, and attention extreme diets receive can cause a person to either minimize or fail to fully realize how unbalanced eating has impacted their mental and physical health. This situation occurs for both type 1 and type 2 diabetes because these conditions require an awareness of carbohydrates while balancing activity and medication, if needed, in order to minimize blood sugar elevations. The association between diabetes and disordered eating has previously focused on youth, and until recently, little attention has been given to older adults with type 2 diabetes. 

How DEB impacts diabetes

Recent research by Garcia-Mayor estimates that disordered eating behaviors may affect up to 40% of patients with type 2 diabetes mellitus! The reason why these behaviors may have slipped under the radar is that the predominant clinical forms of disordered eating are lesser-known eating concerns including Other Specific Feeding or Eating Disorder (OSFED), Night Eating Syndrome (NES) and Binge Eating Disorder (BED). 

The human body is constantly changing, and this requires that the overall focus of diabetes care center on an awareness of situations that cause blood sugar levels to change while taking steps to prevent adverse reactions such as high and low blood sugar. The usual suspects that cause erratic blood sugar include carbohydrates and medication, as well as unexpected culprits

like digestion, stress, sleep, exercise, illness, fat, fiber, alcohol and more. Yet the focus on food seems to dominate the headlines, fueling DEB-D.

The impact that Disordered Eating Behaviors, or DEB, has in diabetes care is challenging to quantify because disordered eating isn’t a static occurrence. Erratic blood sugar levels result from erratic eating, limited consistency with medication, fear and guilt from adverse reactions to medication, eroded provider/client trust, and the decreased desire to seek medical care due to shame, self-blame and guilt. The following screening questions highlight how DEB also creates a sense of self-doubt and fear: 

  • “Have you had a definite fear of losing control overeating?” 
  • “Are you feeling disgusted with yourself, depressed, or very guilty after overeating?”

The impact of DEB in diabetes care is complex because there is an increasing emphasis on weight loss as being a possible ‘cure’ for diabetes as well as a societal normalization of extreme diets which makes disordered eating behaviors familiar and less noticeable. Adding to the complexity is the infrequent screening for disordered eating in older adults, or as part of a type 2 diabetes diagnosis. Together, these two issues obscure the frequency and severity of DEB in diabetes. Current estimates of DEB frequency in diabetes patients indicate that it may affect as many as 11.5 million people. This mind-boggling prevalence of DEB in diabetes is prompting professionals to challenge the ethical value of promoting or condoning radical lifestyle change to achieve weight loss.  

Instead of Weight Loss

Healthcare providers can take steps to minimize the risk of, and the harm associated with, DEB in diabetes for all clients. This begins with a shift to a weight-neutral approach to diabetes care. Changing the emphasis from weight loss, which reinforces the blame, shame, and guilt cycle, to promoting evidence-based behavioral changes such as the AADE 7 self-care behaviors is an excellent place to begin. Professionals can explain that the nutritional focus is no longer on the restriction of calories or placing foods into a binary list of good/bad choices.  Healthcare professionals’ focus should pivot to what is working for the client, and to make an effort to affirm behaviors which help clients nourish the body. Counseling suggestions would reinforce the importance of basic nutrition to the body, eating at regular meal times, eating a varied diet, an awareness of carbohydrates, and aiming for a balance of macronutrients at meals. 

Empathizing with the desire to eat low nutrient foods, instead of criticizing it, may be unfamiliar for providers, but it allows the conversation to move away from behaviors that are harmful to refocus on what is working.  For example: “I completely understand the desire to eat ‘x’, and I’m curious as to what helps you manage your blood sugar in the face of these temptations?” or “I think food cravings are normal, but what helps you balance your carbs?”  Additionally, nutrition recommendations extend beyond food to include awareness of socio-economic and environmental forces which create barriers to self-care and the honoring of internal cues for hunger, fullness, and satiety independent of a person’s weight. In these situations, reflecting back on how these variables are impacting balanced meals can sound like, “Noticing your hunger has helped you not overeat.” or “Having a plan ‘B’ helps you deal with situations that you didn’t anticipate.” 

Weight neutral diabetes is a universal precaution that can stop perpetuating disordered eating behaviors, weight cycling, and weight stigma, while improving the overall well-being of the client. The following weight neutral resources are available for professionals wanting to learn more about DEB and diabetes.

  • Diabetes Counseling and Educational Activities – Book and CPE
    • “I loved the practical activities that make concepts easier for clients to understand. Thank you for these great ideas in an easy-to-read format!!!” -K.A., RD, Canton, OH
    • “This program was fantastic. Lots of practical, realistic and creative information. It was terrific–thank you!”  -J.B., RD, San Diego, CA 
    • “This course really stretched and challenged my thinking. It’s a very different approach then I’ve ever learned.This gave me a lot to think about, and probably change. Thanks so much!” -K.B., RD, West Chester, PA
  • Eat What You Love, Love What You Eat with Diabetes – Book, Self-paced client program and Professional Training.
  • WN4DC Symposium this is a self-paced, 16 CPE training which is broken down into four tracks: Nuts and Bolts about diabetes, Weight Neutral Care, Counseling and Disordered Eating. You can purchase one or all-four tracks.
  • WN4DC Mini-counseling Course – Bring weight neutral motivational interviewing, or MI to your counseling session. This two part course reviews the MI mnemonic O.A.R.S. It is organized as a two part program providing 6 CPE.
    • “She gives examples of how to phrase things and also offers great analogies that are easily understood and thought-provoking”  — Mandy
    • “Addresses how to respond to client’s comments or perceptions about their weight, their behaviors, and their attitudes regarding managing diabetes with reflective statements and MI.”  — Tobi
    • “A forward-thinking way to help patients learn to “un-diet.” — Kelly


García-Mayor R, García-Soidán F. Eating disorders in type 2 diabetic people: Brief review. Diabetes & Metabolic Syndrome: Clinical Research & Reviews. 2017;11(3):221-224. doi:10.1016/j.dsx.2016.08.004

AADE Self-care 7. Published 2019. Accessed December 30, 2019.

Zuijdwijk C, Pardy S, Dowden J, Dominic A, Bridger T, Newhook L. The mSCOFF for Screening Disordered Eating in Pediatric Type 1 Diabetes.

Yanovski S, Marcus M, Wadden T, Walsh B. QEWP-5, The Questionnaire on Eating and Weight Patterns-5: An updated screening instrument for binge eating disorder.

Eating Disorder Questionnaire Examination, EDE-Q Accessed December 30, 2019.

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