Diabetes and Eating Disorders

What Is Diabulimia?

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diabulimia in women
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Research suggests that women with Type 1 diabetes are 2.4 times more likely than women without diabetes to develop an eating disorder, and 1.9 times more likely to develop subthreshold eating disorders. If a person with diabetes has an eating disorder or misuses insulin to lose weight, the condition is often called diabulimia.

Diabetes

Diabetes is a disease that occurs when one’s blood glucose is too high as a result of problems with the hormone insulin.

When food is eaten, the body converts it into glucose that enters the bloodstream. Insulin is a hormone made by the pancreas that helps turn glucose into energy that can be used by the body’s cells. Without a properly functioning insulin system, the body cannot break down glucose. It stays in the bloodstream and can be very dangerous.

Type 1 Diabetes

There are two types of diabetes. Type 1 diabetes was previously called “juvenile diabetes,” because it was most often diagnosed in childhood—however, it can develop at any age.

If you have Type 1 diabetes, your immune system attacks and destroys the cells in your pancreas that make insulin, so your body does not generate any. You must, therefore, take insulin daily in order to process your food properly and reduce your blood glucose levels.

Type 2 Diabetes

Type 2 diabetes was previously referred to as “adult-onset diabetes” because it occurred mostly in adults.

Today, it is increasingly being diagnosed in younger people and has become the most common form of diabetes.

In Type 2 diabetes, the body continues to make insulin, but it develops an insulin resistance and is incapable of using it properly. Type 2 diabetes is initially treated with lifestyle changes and oral medications—eventually, these individuals often have to take insulin as well.

Diabulimia

Deliberately not taking or misusing insulin to cause weight loss is a unique purging behavior that is available to individuals with Type 1 diabetes. This can be accomplished by decreasing the prescribed dose of insulin, omitting insulin entirely, delaying the appropriate dose, or manipulating the insulin itself to render it inactive.

This manipulation of insulin among people with Type 1 diabetes is a condition that is sometimes referred to as “diabulimia.” In medical terms, it’s referred to as ED-DMT1. In the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5), the criteria for compensatory behaviors for bulimia nervosa include “misuse of medications,” which means that if binge eating is present, this type of eating disorder can be diagnosed as bulimia nervosa.

Diabulimia is sometimes also used to refer to any combination of diabetes plus eating disorder. Some people with diabetes may continue taking their insulin appropriately, but may still experience symptoms of an eating disorder such as anorexia nervosa, bulimia nervosa, or binge eating disorder.

Symptomatic behaviors may include dieting, fasting, binge-eating, and a range of compensatory and purging behaviors that can directly interfere with optimal diabetes management.

A recent study by Gagnon and colleagues found that close to half of all people with diabetes report having disturbed eating. However, among the majority of these, criteria for a formal DSM-5 eating disorder are not met.

The most frequent ED diagnoses found in people with diabetes were binge eating disorder (BED) (10 percent of people with Type 1 and 21 percent of people with Type 2) and bulimia nervosa (3 percent of both Type 1 and Type 2).

The Link

We don’t know exactly why people with diabetes have higher rates of eating disorders and disordered eating, but we have some theories.

For one thing, diabetes is strongly associated with a number of the risk factors for eating disorders, including depression.

Another cause may be the weight gain pattern of diabetes. At the time of diagnosis, people have often lost a significant amount of weight. The introduction of insulin may result in rapid weight gain, which can cause distress and heighten temptation to manipulate insulin in people who are genetically vulnerable.

Another issue is behavioral. The intense attention to food portions and nutritional information taught as part of traditional diabetes management, which is similar in some ways to an eating disorder mindset, may put patients at greater risk for restriction and binge eating.

Signs

Unfortunately, many professionals who treat people with diabetes may not recognize eating disorders among their patient population. How can these be detected?

The most obvious sign of an eating disorder in someone with diabetes is weight loss. Another common sign is poor blood-glucose control—as measured by elevated A1c levels—particularly if the person has a prior history of good control.

Professionals may also want to be attuned to the classic symptoms of diabetes (e.g., excessive urination, extreme thirst, constant hunger, fatigue) and common symptoms of eating disorders (e. g., heightened concerns about shape and weight, excessive exercise, dietary restriction, and skipping meals).

Consequences

Patients with Type 1 diabetes and disordered eating are generally in poorer control of their diabetes and therefore are at greater risk for the entire range of life-threatening diabetes complications.

The most serious short-term complication is diabetic ketoacidosis—a buildup of ketones that occurs when the body can't utilize glucose. It causes the blood to become acidic—which is a medical emergency.

Other potential consequences include kidney failure, nerve damage, damage to the retina, loss of vision, heart disease, stroke, and coma. Patients with diabetes and eating disorders also have increased rates of hospital and emergency room visits and higher mortality rates.

Treatment

Providers who encounter diabetes on a regular basis should be able to recognize the signs and symptoms of eating disorders, but they may not. Few studies have examined specific treatment interventions for patients with diabetes and eating disorders. The treatment of these two conditions requires a specialized and coordinated team approach.

Some patients may need medical or psychiatric hospitalization until they are stable enough for outpatient treatment. Outpatient teams should include a psychotherapist, a dietitian, and an endocrinologist, at a minimum, and team members should communicate frequently. Laboratory tests should be monitored frequently.

Regular and flexible eating patterns must be established because dietary restriction can trigger binge eating. Patients are commonly asked to keep food records and can also track their blood sugar levels in order to best manage their diabetes.

There are several organizations that help patients with diabetes and eating disorders, including the Diabulimia Helpline,  Diabetics with Eating Disorders, and We are Diabetes.

A Word From Verywell

People with diabetes and eating disorders may be ashamed and reluctant to seek help. However, the consequences of these combined disorders can be dire. If you or a loved one is experiencing disordered eating and diabetes and especially if there is insulin manipulation, please reach out for help.

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Article Sources
  • Abascal, Liana and Ann Goebel-Fabri, Diabetes and Eating Disorders, 2018.  Clinical Handbook of Complex and Atypical Eating Disorders. 221-234. Oxford University Press. New York.
  • Colton, Patricia A., Marion P. Olmsted, Denis Daneman, Jamie C. Farquhar, Harmonie Wong, Stephanie Muskat, and Gary M. Rodin. 2015. “Eating Disorders in Girls and Women With Type 1 Diabetes: A Longitudinal Study of Prevalence, Onset, Remission, and Recurrence.” Diabetes Care 38 (7): 1212–17. doi: 10.2337/dc14-2646.
  • Gagnon, C., Aimé, A., and Bélanger, C. Can Patients with Diabetes Detect their own Eating Disorder? The Need for A Better Understanding of 004 Eating Pathology in Diabetes. Curre Res Diabetes & Obes J. 2017; 3(2): 555608. DOI: 10.19080/CRDOJ.2017.03.555608