Eating Disorders and Diabetes: Diabulimia and Other Diabetes-Related Risks
Written by CCTC Staff Writer
Diabetes is a serious illness that requires constant monitoring of one's diet, exercise, the body's blood sugar levels, and (if applicable) medication. While diabetes on its own can be hard to manage, all that focus on food, exercise, and the body can cause another dangerous disease — diabulimia.
In this article, you'll learn:
What kinds of eating disorders those with diabetes are at risk for
How managing diabetes can put someone at risk for an eating disorder
What diabulimia is
Consequences of diabulimia
Why it's so hard to treat people who have diabetes and an eating disorder
A lot of eating disorder recovery is rooted in eating intuitively, without worrying about what you're eating or judging yourself for having what you want. With diabetes, a disease that requires people to "watch what they eat," it's much harder to recover from an eating disorder.
But it is absolutely possible.
Related: Want to learn more about intuitive eating, or how to stop being your own food police? Read this.
Diabetes: Definition and Subtypes
Diabetes is a disease that happens when your blood glucose levels (also known as blood sugar) is too high. We get blood glucose from the food we eat.
We also need insulin, a hormone produced by the pancreas, to get glucose out from food and into cells to be used for energy. But sometimes the body does not make enough insulin or use it efficiently enough— or it may not make any insulin at all. In these cases, glucose stays in your blood and can't be used by cells.
Over time, the buildup of glucose in the blood can cause serious health problems, such as:
Heart disease and stroke, due to damaged blood vessels
Kidney disease
Eye problems such as low vision and blindness
Dental diseases such as infection, gum disease, and dry mouth
Nerve damage due to chronic high blood glucose
Foot problems such as cuts and infection that you don't feel due to nerve damage and low blood flow to the appendages (in extreme cases, one might need their foot amputated to cut off a bad infection in the foot)
Type 1 Diabetes
People with Type 1 diabetes cannot produce any insulin in the body. This is because their immune system mistakes insulin-producing cells in the pancreas as infectious cells. Their immune system then targets and destroys these cells, so the pancreas stops making insulin.
Without any insulin, blood glucose levels are chronically high and the cells can't use any of it for energy. People with Type 1 diabetes need to take insulin (in the form of an insulin shot) every day to stay alive. Type 1 diabetes is usually diagnosed in childhood or early adulthood, but can develop at any age.
The disease is believed to be a combination of genetic and environmental factors. Researchers believe the biggest environmental factor is a viral infection early on in life that triggers the immune system's attack response to insulin-making cells.
Treatment for Type 1 diabetes involves insulin injections to control blood glucose levels, along with the close monitoring of weight, diet, and exercise.
Initial Weight Loss with Type 1 Diabetes
Unexplained weight loss is one of the most obvious side effects of Type 1 diabetes. Since the body does not have any insulin, cells can't get fuel from food and they have to get it elsewhere.
The body starts breaking down fat to use as a fuel source, and a person with untreated Type 1 diabetes rapidly loses weight.
In a diet-obsessed society that values thinness and weight loss, individuals may not want to accept help for their diabetes.
Type 2 Diabetes
People with Type 2 diabetes cannot produce enough insulin or use insulin well enough to have normal blood glucose levels.
Type 2 diabetes typically begins with insulin resistance, a condition where the muscles, liver, and fat cells do not use insulin efficiently. Because insulin is not used well, the body needs more of it to help glucose enter the cells.
At first, the pancreas can make enough insulin to meet the increased demand. But after a while, it can't keep up, and glucose levels rise. Like Type 1 diabetes, Type 2 diabetes is caused by a combination of genetic and environmental factors.
The disease is strongly linked to weight, and specifically to how body fat is distributed. When body fat is distributed more around the abdominals, the likelihood of Type 2 diabetes developing increases.
This is because insulin resistance is connected to metabolism, and metabolism is affected by adipose tissue (aka body fat). As you grow older, weight and insulin sensitivity fluctuates, which is why Type 2 diabetes is more common in middle-aged and older people. You can develop Type 2 diabetes at any age, though.
Treatment for Type 2 diabetes involves the close monitoring of weight, diet, and exercise. Those with Type 2 diabetes may be prescribed medication, usually oral ones. Some medications are insulin-based, while others are not.
Initial Weight Gain with Type 2 Diabetes
For individuals with Type 2 diabetes, their bodies often overproduce insulin to try and manage high blood glucose levels.
Insulin is also a hormone that promotes the storage of body fat and to block the releases of fat from fat storage, which leads to weight gain for people with unmanaged Type 2 diabetes.
Most people who experience weight gain prior to diabetes treatment try to lose weight, usually through aggressive dieting. And they don't usually succeed due to insulin problems.
Yo-yo dieting is highly associated with eating disorders, specifically binge eating disorder and bulimia.
Eating Disorder Risk Factors Associated with Diabetes
Weight Gain Due to Diabetes Medication
Insulin shots and medications are the most common treatments for diabetes. Once the body has adequate insulin, the body can start taking in more glucose from food and use it for energy.
For people with Type 1 diabetes, this typically translates to weight gain, since the body no longer needs to break down body fat to use for energy.
For people with Type 2 diabetes who take insulin-based medications, diabetes treatment often means weight gain or difficulty losing weight. This is because insulin-based medications often cause the body to hold onto fat.
Rapid weight gain, or the inability to lose weight, can drive a person to disordered behaviors to manage weight.
Controlling Food Intake
To manage diabetes, an individual has to:
Eat several times a day, even when they're not hungry, to maintain proper blood glucose levels
Monitor the amount of carbohydrates they take in (as carbohydrates are the biggest food source of blood glucose)
Monitor overall amounts of nutrition intake (aka counting calories)
Prepare themselves before eating, by measuring blood glucose levels and/or taking insulin medications
Follow prescribed diets
Many individuals even use their diabetes diagnosis to restrict entire food groups and food intake in general. This mostly goes unnoticed, since a part of diabetes treatment is monitoring carbohydrate/sugar content.
Other individuals struggle with “food rules,” so much that they end up developing disordered binge eating patterns, and eventually, a full-blown eating disorder.
Fluctuations in Appetite
Many “diabetes diets” leave individuals constantly hungry. Low blood sugar levels can also trigger extreme hunger.
And more than that, an individual with diabetes and an eating disorder may take low blood sugar as “permission” to have the foods they don’t usually allow themselves, and binge eat those “off-limits” foods.
The emotional stress that comes with a chronic illness, constantly watching what you eat, and a changing body can all contribute to binge eating as a form of self-soothing. Binge eating can turn into a full-blown eating disorder, and can cause serious diabetes complications, too.
Weight Bias and Diabetes-Related Stigma
Diabetes, especially Type 2 diabetes, is not well understood by the general population.
Many people believe that people develop Type 2 diabetes because of their diet and activity-levels alone. However, Type 2 diabetes is a combination of genetic and environmental factors. Weight and food choices alone cannot account for the development or treatment of Type 2 diabetes. Yet, many healthcare providers prescribe weight loss as a way to “fix diabetes,” which further promotes diabetes stigma.
Medical professionals hyperfocusing on weight as opposed to blood glucose level management is severely distressing for many, and can lead to guilt, shame, depression, and binge eating.
Related: This is the effect of weight stigma on eating disorder treatment and recovery.
Comorbid Mental Illnesses
The stress and anxiety that comes along with managing diabetes can cause psychiatric illnesses such as depression and generalized anxiety disorder. These can also cause eating disorders.
Related: This is how comorbid diagnosis and treatment works.
Diabulimia: A Diabetes-Specific Eating Disorder
Diabulimia is an eating disorder that involves restricting insulin injections or medication for the purpose of losing weight.
It's more common in individuals with Type 1 diabetes, for two main reasons:
Type 1 diabetes patients often lose weight before treatment, and gaining weight after rapid weight loss is highly distressing.
Type 2 diabetes patients can manage diabetes with non-insulin based medications, so they have more incentive to take them.
Three Variations of Diabulimia
According to the National Association of Eating Disorders, there are three main variations of diabulimia:
Binging on food and restricting insulin (bulimia type)
Restricting insulin in addition to significantly restricting food (anorexia type)
Generally restricting insulin regardless of the amount of food eaten (OSFED type)
It’s always dangerous to restrict life-saving insulin, no matter how much food an individual consumes at any given time.
Signs and Symptoms of Diabulimia
As with any eating disorder, individuals with diabulimia hyperfocus on food, shape, and weight. But, as this disorder is specifically related to diabetes, there are some unique signs and symptoms to look out for.
Emotional Signs
Fear of low blood sugars
Fear that “insulin makes you fat”
Extreme anxiety concerning body image
Depression and/or anxiety
Behavioral Signs
Increasing neglect of diabetes management
Secrecy about diabetes management
Avoiding diabetes related appointments
Extreme increase or decrease in diet
Restricting certain food or food groups to lower insulin dosages
Avoids eating with family or in public
Discomfort testing/injecting in front of others
Overly strict food rules
Preoccupation with food, weight and/or calories
Excessive and/or rigid exercise
Increase in sleep pattern
Withdrawal from friends and/or family activities
Infrequently filled prescriptions
Physical Symptoms
A1c of 9.0 or higher on a continuous basis
A1c inconsistent with meter readings
Unexplained weight loss
Constant bouts of nausea and/or vomiting
Persistent thirst and frequent urination
Multiple DKA or near DKA episodes
Low sodium and/or potassium
Frequent bladder and/or yeast infections
Irregular or lack of menstruation
Worsening or blurry vision
Fatigue or lethargy
Dry hair and skin
Health Problems Associated with Diabulimia
Short-Term Problems
Slow wound healing
Staph/bacterial infections
Yeast infections
Muscle atrophy
Inconsistent/absent menstrual cycle
Severe dehydration
Electrolyte imbalances
Long-Term Consequences
Eye problems such as retinopathy (black “spots” blurring vision due to blood “leaking” into the eyes)
Peripheral neuropathy, which causes a stabbing, numbing, or feeling of weakness in the hands, arms, legs, and/or feet
Stroke
Kidney, liver, and/or heart disease
Coma
Death
Diabulimia requires complex treatment, and there are many obstacles to recovery.
With other forms of eating disorders, treatment involves taking emphasis off of numbers, exact caloric and nutritional content, and lifting all “food rules.” But a person with diabetes, even someone with diabetes and an eating disorder, can’t just stop monitoring their intake.
Treatment centers have to take into account this situation when treating someone with both conditions. Individuals in treatment for diabulimia also need medical stabilization and insulin monitoring, which may not be available at all eating disorder treatment centers.
But after medical stabilization, individuals can begin the psychological work of repairing their relationship with food, their bodies, and their diabetes management.
Even though diabulimia is complex, recovery is possible.
Diabetes is a lifelong condition — but you can absolutely recover from diabulimia with diabetes-informed treatment.
If you or a loved one is suffering from an eating disorder, take the first step today and talk to someone about recovery or simply learn more about the holistic eating disorder recovery programs we offer.