Warning: This column discusses eating disorders and disordered eating
Diabetes and Me - There is an app on my phone that haunts me. It sits there on the screen, bright blue and shiny, taunting me to open it. It's a calorie counting app.
Megan Whelan. Photo: RNZ / Rebekah Parsons-King
When I started to overhaul my diet to manage my type two diabetes, it was really useful. Knowing how much protein was in my dinner, how many carbs, how much fibre was important information. But to get that information, I had to weigh everything I ate and obsessively read nutritional information.
As I've written before, it took all the joy out of preparing a meal, but it also started to take over parts of my brain. And while the macro information is useful, knowing how many calories I consume in a day isn't information I particularly want. Because that feels like the fastest track to me restricting not just the kinds of foods I eat, but an unhealthy obsession with how much - or in fact little - I consume.
The temptation to give myself a calorie target that is far too low to be healthy, to satisfy that voice in the back of my head, is strong.
I am sure there are many people for whom that data is an essential, and normal part of their lives. But for those of us who grew up trying fad diet after fad diet, or heard an endless refrain of "calories in, calories out," it's troubling.
Dr Roger Mysliwiec is an eating disorder specialist and director of the New Zealand Eating Disorders Clinic.
He says the anxiety I wrote about last week isn't unusual for someone who's newly diagnosed and that what might have been helpful is a diabetes specialist or a GP who understood that such a new diagnosis could, for someone like me, create a lot of anxiety that might lead to an exaggerated and obsessive control of my eating habits.
"[Someone who was] psychologically informed enough to be able to talk to a patient who's newly diagnosed, and is worried, to help them find a good balance between the need to take care of their diabetes and the need to still enjoy food and life. And also give them a reality check about the condition."
Dr Mysliwiec says disordered eating can - and does - happen across a lot of society at different times.
"Basically, most diets could be described as disordered eating." He doesn't mean medically-informed diets, like a person with coeliac disease who doesn't eat gluten. Or indeed, someone with diabetes who limits their carbs.
"Many diets are in response to wanting to lose weight, and start to become radical, and somewhat odd." He points to the keto diet, which has some evidence, in the context of treatment of epilepsy, but most people aren't following it correctly, or with the advice of a medical professional.
"[People do] these kinds of restrictions for four weeks, and then 'finally I can eat all this again,' and it leads to that typical yo-yo effect. Losing weight is reasonably simple, easy. But maintaining a low weight is close to impossible, at least with these common diets."
That doesn't mean most people who engage in disordered eating have an eating disorder - that has specific diagnostic criteria and a big genetic component. (Dr Mysliwiec says there's a combination of many genes that make up a genetic predisposition to eating disorders, including metabolic genes.)
There's a very specific, and dangerous, disorder called Diabulimia suffered by people with type 1 diabetes - insulin dependent diabetes. The onset of type 1 tends to be at a young age, and usually means dieting - not eating certain things - plus, there's a risk of weight gain when having to compensate for hypoglycaemic episodes as part of diabetes management.
People suffering from Diabulimia don't use the insulin they need, which drives up their blood sugar significantly. That means they can't convert carbohydrates into energy and end up losing weight.
It also means they're at severe risk of ketoacidosis coma: "It's basically full-on untreated diabetes. And the significant secondary risk is that they end up with all these secondary complications, microvascular complications, which can lead to… [things like] blindness and kidney failure."
He says it's high risk, and the risk of developing an eating disorder among type 1 diabetics is significantly higher than the general population.
So, what to do around the anxiety about what I can and can't eat now?
Dr Mysliwiec says, for someone with the genetic predisposition, engaging with disordered eating is a common pathway to ending up with an eating disorder.
"The gist is one having some awareness, of having some balance, and being aware of the risk of taking things too far… if you already have that vulnerability, and start to engage in bizarre diets, then you're putting yourself at extreme risk."
He points me to a study conducted in the 1940s - immediately following World War II, where volunteers were put on a starvation diet and observed.
"Starvation affects our thinking and behaviour around eating… it becomes increasingly more important to our mind, to the extent it becomes obsessive... leading [to] compulsive, often even bizarre behaviour."
The APA writes about the experiment: "Hunger made the men obsessed with food. They would dream and fantasize about food, read and talk about food and savor the two meals a day they were given. They reported fatigue, irritability, depression and apathy. Interestingly, the men also reported decreases in mental ability, although mental testing of the men did not support this belief."
The men in the study didn't have an eating disorder, but they were experiencing severely disordered eating, Dr Mysliwiec says.
"Good healthy eating, non-comfort eating, a fibre rich diet - that's not a diet. Someone diagnosed with diabetes should stay away from highly processed, highly sugary foods and high fat foods… or only have it once in a while. That's not a diet."
But balance is key, as is talking to people who can give good advice, he says. "Ultimately, one needs to look at the big picture. One needs to balance the possible cost of loss of enjoyment and pleasure in life when following an overly restrictive diet against the hoped for physical benefit, particularly if I am getting more and more restricted and unhappy," he says.
"If one gets too overly focussed on one thing, then the cost is too high. That's a challenge we have in life all the time."
