Type I Diabetes & Eating Disorders

Identifying Causes & Symptoms

Most people are familiar with the more widely known eating disorders anorexia nervosa, bulimia nervosa and even binge eating disorder, but few recognize the link between Type I diabetes and eating disorders. The term "diabulmia" has often been used to refer to this life threatening combination and the unhealthy practice of depriving insulin to manipulate or lose weight.

Individuals diagnosed with Type I diabetes must take regular doses of insulin to regulate their blood glucose levels. When individuals are diagnosed with Type I diabetes (usually in childhood or adolescence) they must begin taking insulin, and often gain weight as the body stores the glucose as fat. For many young people, the initial weight gain is difficult to tolerate, especially when they know that skipping doses of insulin can help to manage thier weight.

This risky practice can have catastrophic health consequences. Often these individuals take just enough insulin to function and consistently feel dehydrated, fatigued and irritable and face long-term health complications ranging from blindness and nerve disorders to kindey failure and diabetic ketoacidosis (an acidic buildup in the blood resulting from inadequate insulin levels).

"Diabulimia" is a relatively new term and the link between Type I diabetes and eating disorders is not yet recognized as a medical condition and as a result is greatly under-diagnosed and left untreated. The first step in treating this dangerous disorder is understanding the causes and symptoms.

Potential Causes

Patients diagnosed with Type I diabetes are two and a half times more likely to develop and eating disorder than other women. Steve Graybar, Ph.D., a licensed psychologist, speculates that a number of factors play into the occurrence of Type I diabetes and eating disorders:

The standard treatment for Type 1 diabetes focuses on dietary restriction, counting carbohydrates, and paying close attention to weight, body, and food intake, which can trigger an eating disordered mindset.
With diabetes, food is more than fuel for the body – it becomes a target of daily focus. Rather than a time of nurturing, mealtimes are rife with conflict and distress, as well as injections, finger pokes, and other less-than-pleasant activities. As a result, insulin becomes the enemy and young people will go to extremes to avoid taking it.
A certain degree of rigidity is required to effectively manage diabetes, which can lead to a struggle for autonomy, personal independence, and a sense of control – all hallmarks of anorexia, bulimia, and other eating disorders. In this sense, diabulimia and other eating disorders become a way to regain control.
Finding out that you have Type 1 diabetes can be incredibly stressful, especially for an adolescent or young adult who is told she will have to take shots for the rest of her life. Without the appropriate coping strategies and life skills, the diagnosis can be so overwhelming that young people turn to eating disorders to cope.

"A diagnosis of Type 1 diabetes is like dropping a bomb on a family," says Dr. Graybar. "One day the child has the flu, and the next she has a life-threatening illness that is never going away and that requires an incredible amount of complex treatment just to maintain a basic quality of life."

Naturally, outside observers question, How could any amount of weight loss be worth the risk of death and long-term health complications?" But for many teens, being thin seems more important than life itself. The threats of death, falling into a coma, blindness, and kidney failure seem like complications that could only arise 40-50 years from now – a time so far into the future that is almost impossible for a teen to imagine.

“Restricting insulin intake is an understandable but self-defeating strategy, explains Dr. Graybar. Even though most teens and young adults understand the risks intellectually, they feel a sense of invulnerability. Others are fatalistic and feel like theyre going to die before they experience any complications, so they figure why not live fast and hard in the time that they have? Unfortunately, many individuals struggling with this condition live long enough to just begin to want families, careers, and long, fulfilling lives but a great deal of damage has already been done.”

Symptoms

Medical professionals and researchers have identified the following warning signs that an individual with diabetes may also be developing an eating disorder:

Changes in eating habits (typically, eating more but still losing weight)
Rapid weight loss or weight gain
Poor metabolic control despite the appearance of compliance
Low self-esteem or preoccupation with body image, weight, or food intake
Frequent urination, excessive thirst, or high blood sugar levels
Low energy, fatigue, shakiness, irritability, confusion, anxiety, or fainting
Purging behaviors (such as excessive exercise or the use of laxatives)
Discomfort with eating or taking insulin in front of other people
Hoarding food
Unwillingness to follow through with medical appointments
Recurrent diabetic ketoacidosis

Diagnosis and Treatment

"The occurrence of 'diabulimia' is notoriously difficult to diagnose because the symptoms don't necessarily present as 'classic' anorexia or bulimia," says Kathryn Eckert, M.D., a board certified pediatric endocrinologist. In addition, individuals often feel ashamed and embarrassed of their behaviors and will go to great lengths to keep their condition a secret from family and mecial personnel.

The most important thing for parents to do is stay involved in their children’s lives and help them monitor and learn about their diabetes. Experts advise parents to know their child’s A1C value (also known as glycated hemoglobin or HbA1c), which reflects blood sugar control over the past 2-3 months, and why it has reached a certain level.

In her own practice, Dr. Eckert begins looking for signs of insulin manipulation and eating disorders in patients around age 13. When a female patient between the ages of 13 and 30 presents with chronically high A1C levels, there is cause to suspect issues with weight, food, and body image, she says.

Research by Denis Daneman, published in Diabetes Spectrum in 2002, supports these observations. Daneman’s studies suggest that 1 percent of girls at 12 years old are manipulating insulin. By age 15, that number increases to 14 percent, and by age 19, 34 percent admit to manipulating their insulin intake. In a separate study, nearly one-third of the participants indicated that they had previously skipped or restricted their insulin in order to lose weight.

“The situation is dire, and early intervention is vitally important,” advises Dr. Graybar. “As a medical professional, it is imperative to muster the courage to ask the tough questions without accepting rolled eyes, a crinkled nose, and a loud huff as the final answer. We keep asking and keep assessing until young women get the help they need.”

Diabetes and eating disorders are both chronic, life-threatening diseases that result in more frequent hospitalizations and serious medical complications. In many cases, treatment is a matter of life or death.

Dr. Graybar and Dr. Eckert lead the Diabetes Program at the Center for Hope of the Sierras. Patients work with a collaborative team of doctors, nurses, dieticians, and therapists who intimately understand both issues, and who offer the ideal combination of medical management, therapy, and social support to help patients effectively manage their diabetes and recover from their eating disorders.

“People with poorly controlled diabetes are facing the threat of permanent damage to their health and are often one short step away from requiring hospitalization,” says Dr. Eckert. “The stakes are so high, we simply can’t afford to look the other way.”