In this episode of Diabetes Care Conversations, we explore the complex and often overlooked intersection of disordered eating and diabetes, highlighting how routine management behaviors can unintentionally contribute to and prevent unhealthy relationships with food. Vandana Sheth, is joined by Megrette Fletcher, M.Ed, RDN, CDCES, and Zehra Haider, MD, who share practical insights on recognizing subtle warning signs, using simple screening approaches, and fostering compassionate, team-based care to better support patients.
Additional Resources
Megrette Fletcher
If we take a step back and we look at what eating disorders are, they're a coping mechanism. So our clients are actually trying to help themselves, and they're trying to help themselves cope with a very challenging condition. Diabetes is very challenging.
Vandana Sheth
Hello and welcome to ADCES podcast, Diabetes Care Conversations. In each episode, we speak with guests from across the diabetes care space to bring you perspectives, issues, and updates that elevate your role, inform your practice, and ignite your passion. I'm your host Vandana Sheth. Today, we are exploring a topic that many clinicians sense in practice, but may not always feel equipped to address directly, disordered eating and people living with diabetes. Managing diabetes already requires careful attention to food, numbers and daily behaviors. And sometimes those demands can intersect with eating patterns in complicated ways. Joining me today are two incredible experts in this space, Megrette Fletcher and Dr. Zehra Haider, who will help us unpack why this issue matters and what clinicians can do better to support their patients. Megrette, let's start with you. Tell us a little bit about your work and how you became interested in this topic.
Megrette Fletcher
Thank you so much. I'm a dietitian at Nourish, which is a virtual platform. And I started in the eating disorder space. Actually, it was the first job I had when I became a dietitian. And, you know, I just really loved working with people to help them have a great relationship with food. So that kind of brought me to this space.
Vandana Sheth
Thank you for sharing that and I know you have some great insights for us. I can't wait to get into that conversation. Zehra, how about you? What drew you to studying disordered eating and diabetes?
Zehra Haider
Well, I'm Zehra Haider. I'm a board certified diabetologist and obesity medicine doctor. I'm currently at the Barbara Davis Center for Diabetes. A big part of my practice is patients with type 1 diabetes. And I started seeing patterns of a lot of them having had a history of disordered eating and being in recovery. And that's what actually inspired me to look a little bit more into it for the American College of Diabetology.
Vandana Sheth
Wow. Again, thank you so much, both of you, for being here. This is such an important and often complex topic, and I'm really looking forward to exploring it with both of you. So to ground the conversation, how do you define disordered eating in the context of diabetes care?
Megrette Fletcher
I think that disordered eating is hard to really understand in diabetes because so many of the things we ask our clients to do are actually kind of gateways into some disordered eating. Without getting too, technical, I think really what we want to understand is when we ask our clients to think about food or calories or weight, these structured meal plans, really talking about having foods off limits we can start seeing how disordered eating and diabetes can really kind of get mixed up and into this. And there's different types of disordered eating. And again, it's a little bit more complicated, but most people are not presenting with an eating disorder. They have kind of a relationship that's not quite healthy with food. But then if we ignore it and we don't pick up on those red flags, it can become an eating disorder and there are specific types of eating disorders and I'll let Zehra kind of go into any more in detail, but we know about the restriction which is more associated with like anorexia or a bulimarexia. And then there's like the bulimia, so that's where we might purge or exercise too much. And then there's this like orthorexia which is kind of perfectionistic.
And then there's binge eating disorder, which is probably the one we see the most.
Vandana Sheth
Zehra how about you?
Zehra Haider
Just to piggyback off of what Megrette said, it's such a big umbrella term. And if you want to keep it simplified for people who may not be as fluent with disordered eating, you have the restrictive behaviors and the overeating behaviors. And there are correlations with type 1, and there's more potentially restrictive eating behaviors and type two where there's more binge eating behaviors. But when you look at it, the relationship with diabetes and food, it's intertwined and you can't really separate the two out. And there's so much focus on numbers and watching things, whether you're watching your insulin doses or your blood sugars every day or for type 2 diabetics, your weight, you know, it's almost like a ticking time bomb for some of these patients where it's not a question of if, but when this presents.
Vandana Sheth
Those were some powerful words that you both shared, know, ticking time bomb. And when you mentioned numbers, it's part of their daily plan to wash those blood sugars, to keep track of the carbs, to titrate their medications. So it's already almost leading up to this pattern. And so as clinicians, what is a common misconception then that we may have or that you've seen in your practice about this population?
Megrette Fletcher
First and foremost is that you can see and you would know when someone has an eating disorder. So eating disorders don't have a look. And I think that's the very first thing. I think a lot of times we imagine that there's a specific look that someone might have and they don't. And I think Zara pointed out that when we look at people with type 1, we're really seeing that many people with type 1 are at risk or at greater risk for that restriction. And so is circling back to that question of what are the things people might miss, which is, again, just the incidence, the number of people. So probably, and I'm reading some numbers to make sure that I get it correct. So about 10 % of people with type 1 diabetes have an eating disorder, and then subclinical eating disorders, 30 to 50%. And so for men, it's about 10 to 20%.
So I think people miss the volume, how many. And when we're dealing with type 2, those numbers are actually much higher. So as high as 50%, so disordered eating in the 40 % range. And I've seen different numbers kind of passed around, but I do definitely see that probably about half of our patients with type 2 diabetes are presenting with some sort of disordered eating. And some point in type 1, we're going to see it.
I also ask people with type 1, one of the things I really like to point out is learning when someone was diagnosed with type 1 diabetes can often really help us. So periods where there's a lot of focus on our body, so you can think like puberty would be a big risk factor. If people are involved in competitive sports, so if you meet somebody who's super, super active or they're on a team or they wanna like get really good on the team, that's another like hmm, let's ask a little bit more. After pregnancy, I think is a big risk. And I also think that menopause is another risk. And I would always point in all of those for women. Again, men, when we start kind of getting into this getting fit or being involved in competitive sports. So those are a couple of things that I like to look for, but really getting curious about when someone was diagnosed with type 1 and also when someone was diagnosed with type 2. So that can be great place just to start a conversation and get curious about their relationship with food. Zehra?
Zehra Haider
I agree with Megrette. With a lot of the data that we look at for disordered eating in type 1 and type 2, the risk is always higher in younger patients. So with type 2, the risk of disordered eating is 50 % in young adults and adolescents. With type 1, there's a 2 to 3 times higher risk of having disordered eating, and it can be as much as 24 % to 30%, depending on the data set that you're looking at. But, and I'll give this as a personal example. I don't know if either of you ever worn a continuous glucose monitor. I have periodically and you know, I have South Asian genes. So we're predisposed to having pre-diabetes and type 2 diabetes. And I've been able to track my blood sugars and you can see like, I ate this and it made my blood sugars go up. Now, you know, I might get a spike into a 160.
And so like, well, I can't eat that, or I have to really limit what I eat. And we're coming into it with me not having lived this life since I was five years old or 12 years old or 18 years old. And so it's this constant burden of these numbers and these alarms going off. It's a setup. And then as clinicians and as physicians, we come from a place of wanting to help our patients.
But I almost wonder if some of that language is triggering for these patients where you're talking about, what did you eat? How much did you eat? Did you take your insulin? And we have to be very mindful because in some of these younger patients, that language may snowball into something much bigger than just their diabetes management.
Megrette Fletcher
Vandana, can I add to what Zehra has just said? So two things that kind of come up and I want to just really highlight. So Zehra really talked about diabetes distress. And I think diabetes distress is something that clinicians should really be looking for. Because if we take a step back and we look at what eating disorders are, they're a coping mechanism. So our clients are actually trying to help themselves. And they're trying to help themselves cope with a very challenging condition diabetes is very challenging. And I think it's really important to understand that the desire, the intention is not malicious. It's self-compassion. They're trying to help themselves. And so again, when we start looking at diabetes distress, when we feel like I'm trying to do everything right and I'm just really burdened by this, you know, having a chronic disease. And we do have screening tools for diabetes distress.
And so if we could really pinpoint distress, we might be able to help people before these things come in. But a lot of times what happens is someone's A1C looks good or, you know, they're like, nope, I'm okay. And so we don't actually get into the distress. And so this leads us to this aerogenic risk factor, which is again, what Zahra was talking about is we as clinicians, again, are not trying to harm, but yet by our questioning, and by our reinforcing behaviors which could be disordered, we are actually harming the patient. So I think it's a really important understanding that it's our curiosity that really helps people kind of come out and really say like, I trust you, you know what, I'm really struggling with food. And that's not gonna be the first thing. It's not gonna be the 10th thing they talk to you about. It's gonna be much down the line and it's gonna be very subtle. And if we're just like, you know, your numbers look great, just keep doing what you're doing, they're going to say, I can't open up to you.
Zehra Haider
And I will throw in there, a little bit of that is also control. Because for our patients with diabetes, know, especially when you have type 1 and you've had it since you were three years old, there's been very little that's been in your control. Or you get diagnosed with type 2 and yes, you know, there's lifestyle factors, but there's also genetics. So again, a lot of times people are just trying to take back some control and there's very little in life that we can control. So they're trying to control this. The other thing I would add is, I think as clinicians, yes, we focus on like, hey, your A1C looks good, your CGM download looks great, or, well, you shouldn't do this. But I think in the framework of the society we're in right now, we're also being pressured to see more people per day, which really limits how much time we can spend with patients.
So, you know, there are practices out there where clinicians are expected to see patients every 15 minutes. There are certain healthcare systems out there where an endocrinologist or a diabetologist may only see a patient in person once a year, and the rest of the visits are telehealth because they're trying to limit clinic staff. So it makes it hard to be like, you know, you've been losing some weight. Is everything okay? You know, or you've gained some weight. Is everything okay? You don't have those...
And across the screen, it's very difficult to make that connection as well. So I think there's a few different factors in there that are kind of adding to the difficulty with being able to have that curiosity, as Migrat said, where it's not always not wanting to know. It's just you don't have the opportunity to want to.
Vandana Sheth
And you know, you both had some amazing info and insights from your perspectives, from your practices, and that really brings it to light. Zehra, especially when you mentioned the South Asian genes and trying on a CDM, I get it. And I was shocked at how almost obsessive I became with the tweaks I could do with my food and the numbers, like if I could trick it or if I could tweak it so I can see how it can spiral out for someone who's trying to manage this all the time. Another thing that you mentioned that was interesting to me was about the lack of time clinicians have sometimes. You're back to back with clients. And that's really where I think diabetes care and education specialists and the team approach can really round out a person's care in this space. So we talked a lot about the risk about, you know, someone in this population with eating disorders and diabetes. I next want to shift towards detecting. And I think, Megrette, you touched on the screening. We know these behaviors can be complex and often hidden. Given that, why is proactive screening so critical in diabetes care?
Megrette Fletcher
Again, we're trying to identify and provide an intervention before things get extreme. And I think that one of my favorite screening tools, and it's not like a validated screening tool, is just to ask your client, what bugs you about diabetes? And if they go, nothing, that's good, I'm fine, then you screen them in a way. It's very casual. But when they come at you and they go, this and this and this and this and let me talk to you about that, that's really telling you that probably the burden of diabetes is pretty high. And that's gonna help you start assessing things going forward. So it's okay for us just to lead with some curiosity and say like, hey, know, what bothers you about diabetes? I have asked that question thousands of times and it's just such a great door opener.
It's a very subtle screening. I also really like the diabetes distress. So when I feel like somebody's in distress, I talk about diabetes distress and I really differentiate, it's not depression. Diabetes distress is different from depression. And then once we do that, then I'm starting to really feel like, okay, we're going down that disordered eating route. That would be where I would, you know, pull in the multi-disciplinary, you know, how do we wanna proceed?
I think for myself, getting into the screening, like what type of eating disorder, I find that I'm not in that role right now. So I would refer somebody out for like a comprehensive treatment where we might be doing that. I'm definitely, you know, on the front lines. And like Zara said, you know, I don't have time to do a super complex screening around diabolin or those kinds of things. But these casual, screenings. And know, Zehra, you have some great tools that you like to talk about as a clinician. And so I would pass it off to, you know, the diabetologists or the endo or the person who specializes more.
Zehra Haider
I will say, and I think one of the big hesitations with screening is, again, there's lack of time and clinicians are like, well, I don't know how to manage this. This is not my skill set. You don't have to have the answers right away, but you have to identify the problem. Because once you know that there is a problem, you really will have the best outcomes for your patients. You can't bury your head in the sand and be like, well, I'm not going to look into this because I don't know how to manage it. And I'm going to keep my fingers crossed that the A1C and everything else gets better and goes away on its own. The other misconception is that it's a very lengthy process and it's not. A basic screening can be something as simple as, hey, it seems like you haven't been filling your insulin as much. What's going on? Well, insulin's really expensive. Are you able to afford groceries? Because sometimes an eating disorder, it's been forced onto you because you simply can't afford it. You can't afford your insulin, so you're like, well, I'm going to eat less, so I don't have to take that much insulin. It could be something as simple as, are you skipping your insulin doses? Because I'm seeing a lot of these rises that I didn't see before. Well, I am because I feel like it's making me gain weight. So, you know, that's a red flag right there.
But there is a validated screening tool. It's called the DEPPS 10. And the ADA had published this in 2010, but you can find it online. It's 10 questions. It really requires, I think, a third or fifth grade reading level, so your patients don't have to be super educated to fill it out or at least go through it with you. And it takes about five minutes.
And it has very direct questions. Like sometimes I skip insulin because I don't want to gain weight, or I eat more when I'm alone compared to when I'm with other people, or my eating makes me feel ashamed. And so it's a very basic questionnaire, but it's a useful tool. And once you've identified the issue, you've built a relationship with your patient. Because a lot of times nobody's asked them. And sometimes just asking them makes the patient feel seen, feel heard. Then you can be like, well, I'm not qualified to treat this, but let me look into resources that we can use to help you.
Vandana Sheth
Really appreciated you both walking us through what proactive screening actually looks like. It's not this complex process. Both of you shared simple questions that kind of lead the pathway to get into this. Have you seen situations where disordered eating was missed for a long time in your practice?
Megrette Fletcher
One of my girlfriends, she has type 1 diabetes, and she's very open about the fact that she had bulimia prior to being diagnosed, and she said, no one asked me. No one asked me prior to getting diagnosed if you've ever had an eating disorder. And, you know, right now she really says, hey, you know, I had diabetes for 50-ish years, and in those 50 years, no one has ever asked her. And she said, I find that so interesting.
And one of the things she said to me yesterday, so we were talking about it yesterday, she said, you know, I have my A1Cs on target and I have asked my providers, are you interested how I keep my A1C on target? And they go, no, just do what you're doing.
Vandana Sheth
Missed opportunity.
Zehra Haider
Yeah, I've seen the seeds of eating disorder, disordered eating in patients who are relatively newly diagnosed because I see them as new onsets and I'm seeing them right as they exit the hospital. And then I'll see them fairly frequently for the first few months. And I've seen so many of them been like, well, I'm just, really limiting my carbs because I don't want to see my blood sugar spike. And so we have this whole conversation about, well, carbs aren't bad carbs are fuel, your body needs carbs and you can always take more insulin and we'll talk about like there is some weight gain with insulin, it's okay, we're gonna work around it but you need to be able to have a well-rounded nutritious diet. Because I try to frame it in terms of you're nourishing your body and it's not like carbs are bad, fats are bad, everything is good, you just have to nourish your body. So it's been one of those things where I think people have done old vision, especially with some of these newer diabetics, because you're going from an A1C of 11 to like seven and a half, and now you're at a 5.9 and everyone's high-fiving and being like, yay, we did it. But it's like, what is the patient doing to get there?
Vandana Sheth
Yeah. And so once disordered eating is identified, supporting the patient often requires more than one professional perspective. So why is a multidisciplinary approach so important in this situation?
Megrette Fletcher
I think we've kind of touched on a lot of it. First and foremost, it's complex. I think it does take a lot of people. you know, somebody might open up to Zara but not open up to me. And so we recognize that, you know, she's going to be able to maybe tell me something that I wouldn't know. And as we communicate with each other, we're getting a clearer picture of what's going on. I definitely find that in the diabetes space, coping. So just really working with our emotional health is really low and I do refer people to therapies because a lot of times, again, as we said, disordered eating is not coming from a place of malice, it's trying to cope. And so a lot of times we need more supports around our coping mechanism. I know, and I'm sure all the dieticians listening out there, we understand that food kind of, it's a thread that runs through so many different things. So people will talk about food and eating and they'll start to cry with me.
I joke with people, pen, paper, and tissues, and they're like, tissues? Why do I need tissues? But they'll say something and it will just hit that emotion. So we recognize that as we work in this multidisciplinary team, we do need to say, like, you know, my client is really trying to be with and process some really big feelings, and food somehow triggers those feelings. There's something about food and eating or body image that's triggering these feelings and that's why we're looking for other supports to come on in. And I feel like that's one of the parts that I really appreciate about working in a team approach. And I think Zara did a really beautiful job of saying by her holding the mirror, know, turn around and saying, let's talk about this. It's okay for you to eat carbohydrates. I think people don't realize how much her permission gives people permission to explore carbohydrates. So I will have people come back and they'll say, well, my doctor said this courageous thing. And when you really ask them, like, was so weird about it? They said carbs are OK. And it's just this very interesting process where they didn't talk about carbohydrates at all, but because they said eating carbs was OK, or our goal is to eat a balanced diet, or our goal is to nourish our body, all of a sudden they come to the dietician and they're like, hey, I want to talk to you about balanced diet. They didn't want to talk to me about a balanced diet earlier. When the provider says something about insulin, all of a sudden, hey, I want to talk with that diabetes educator about my insulin dose, or I want to talk to them more about my pump. I want to talk to them more. So we give each other permission to start exploring the complexity of disordered eating and eating disorders. And I think that that's really a huge part of this.
Zehra Haider
What I would say is you don't want to come to me to fix a broken bone. I know the theory of it, but I can't do it. It has to be somebody who has been trained to do it. So I think this is where that team really is important. You need a dietician or a nutritionist. You need a therapist. And ideally, you want people who are familiar with diabetes. So that's where your CDC ES's are critical but also having therapists in the community who are familiar with diabetes or chronic disease management. I mean, I'm lucky that I live in a community where there's actually several therapists who have diabetes themselves. And we know that and we're sending patients there because they can understand it at a level where a regular therapist may not get the pressures and the stressors. So I think that's where having that team approach is so critical because it takes a village to help our patients. I also don't wanna rush them because I'm also trying to be like, well, let me order your prescriptions, let me do this, and then XYZ for your disordered eating. You need somebody who can focus on that 100%. And I will add over the years that I've done this, I've seen patients who have come in from other endocrinologists or their primary care physicians, patients who are in their 60s and 70s and have had diabetes for decades who are just shocked when I'm like, carbs are okay. Well, I was told no carbs. No carbs are okay. You know, we've got to talk about balance, but carbs are fine. They were told by a doctor in the 80s, like don't ever eat carbs. And that may have been appropriate advice for that time period, but no one's kind of gone back and readdressed it.
Vandana Sheth
So we could have this conversation going on for hours because you both have such great information to share. I'd love to close with a takeaway for our listeners. If a clinician listening today remembers just one thing from this conversation about disordered eating and diabetes, what would you want it to be?
Megrette Fletcher
getting curious about the intention behind the behavior. Is the behavior fueled by fear? Is it fueled by insecurity? Get interested into like, what, why? Why are you choosing this? Tell me more about it. What are you hoping to get? So that curiosity about the intention. And even though the behavior is the same, I'm gonna count carbohydrates, the intention in disordered eating is what changes.
And it's often the motivation behind it, either to be good, to be right, or to avoid certain things. And I think that that fear can really make us very reactive. And so I really encourage people just to kind of get curious about the intention. And I think Zara and throughout this whole conversation really listening.
Zehra Haider
Yeah, I would say don't let your fear hold you back from asking because for us as clinicians, oftentimes it seems like a behemoth, like an eating disorder. How am I going to deal with this? This is not my wheelhouse. But at least ask. And there are resources out there that you can use to help your patients. You don't have to fix everything right away.
You just have to ask so you can help your patient get on that BATS-DO recovery.
Vandana Sheth
Thank you both for sharing those insights. And what I'm hearing from both of you is that awareness and early conversations can make a tremendous difference. Disordered eating and diabetes is complex, but with thoughtful screening and a collaborative care team, clinicians can play a powerful role in supporting patients. So thank you for listening to this episode of Diabetes Care Conversations and engaging with ADCES.
Additional resources are added to our show notes. And remember, being an ADCES member gives you access to many resources, education, and networking opportunities. Learn more about the many benefits of ADCES membership at adces.org slash join. All the information in this podcast is for informational purposes only and may not be appropriate or applicable for your individual circumstances.
This podcast does not provide medical or professional advice and is not a substitute for consultation with a health care professional. Please consult your health care professional for any medical questions.