The promise of quick weight loss is appealing to many, especially young women who are concerned with their appearance. Often, the quest for a thin body and an obsession with food can lead to eating disorders such as anorexia or bulimia. When an individual with insulin-dependent (type 1) diabetes develops an eating disorder, the result can be downright deadly.
In type 1 diabetes, the body does not produce insulin, the hormone required to convert starch and sugar into energy. Without daily insulin injections, glucose is excreted into the urine, rather than being used for energy or stored as fat, and blood sugar levels rise to dangerous levels. In order to survive, the body begins the process of breaking down muscle and fat, resulting in a state of starvation and weight loss. Individuals with type 1 diabetes must be vigilant about their diet, carbohydrate counting, and insulin injections. Ironically, this preoccupation, which is necessary for good diabetes management, may lead some to develop eating disorders, especially once they realize that withholding insulin can result in rapid weight loss.
This practice of purging sugar from the body and losing weight by purposely manipulating or withholding insulin has been termed Diabulimia (a combination of diabetes and bulimia) This disorder is gaining attention in the medical community because of the enormous health consequences associated with it. Short-term complications include severe dehydration, fatigue, and risk of deadly diabetic ketoacidosis, which occurs when “ketones” (acid by-products created when the body burns fat for energy) build up in your blood. Over time, diabulimia accelerates diabetic complications such as blindness, nerve damage, gastroparesis (damage to the nerve that helps move food through the digestive system), kidney failure, stroke, coma and even death.
According to published reports, the behavior is widespread, but may not easily be recognized by primary care providers or family members. It is estimated that as many as one-third of all females with type 1 diabetes, or more than 450,000 women in the US, have engaged in withholding insulin in order to lose weight. Because of increased prevalence and the need to identify the condition and those at risk, the American College of Endocrinology (ACE) and the American Association of Clinical Endocrinologists (AACE) has created this informational video.
Who is at risk?
Diabulimia can occur in anyone with type 1 diabetes, but the behavior is most commonly identified in adolescent and young women between the ages of 15 and 30. Typically, those who practice it have weight or body image issues, and most are in denial that the above complications will ever affect them. For most, manipulating insulin gives individuals a sense of control over their bodies at a time when other aspects of their life feel out of control.
Know the warning signs
The warning signs of diabulimia can vary from person to person, but some important ones to watch for are:
- Preoccupation with body image
- A change in eating habits, especially eating more but losing weight
- Rapid weight loss or weight gain
- Persistent thirst or frequent urination
- Depression/mood swings/fatigue
- Repeated bladder/yeast infections
- HbA1c results that are different from previously-recorded blood sugar levels
- Diagnosis of recurrent diabetic ketoacidosis
- Blood tests that indicate low sodium/potassium
- Secrecy about blood sugars, shots and/or eating
- Missed medical appointments
Prevention and Treatment options
Because young women with type 1 diabetes have three times the risk of developing an eating disorder, it is especially important that they meet regularly with a registered dietitian (RD) who can monitor their diet as well as glucose levels and weight, and make adjustments in calories and carbohydrate content if necessary.
Insulin needs are closely tied to carbohydrate intake, since carbohydrates (found in starches like bread, pasta, rice, potatoes, as well as fruit or juice, milk or yogurt, and sweets and many snack foods), turn into glucose within a few hours after eating. RDs have expertise in carbohydrate counting and can teach patients how to match insulin dosage to grams of carbohydrate eaten. In addition, RDs can educate patients on healthy methods of weight loss if necessary.
Individuals with type 1 diabetes who receive ongoing education and guidance about planning healthy meals and carbohydrate counting have tighter control of their glucose levels. This helps to prevent the dangerous side effects of diabetes. In addition, they are more likely to maintain a healthy weight and hopefully avoid developing diabulimia.
For patients with diabulimia, as with any eating disorder, treatment is most successful with a multi-disciplinary team approach, in order to treat the medical, behavioral, and emotional aspects of the condition. For most patients, this is accomplished by working closely with the patient’s primary care physician, as well as an endocrinologist, a registered dietitian, and a psychotherapist.
Support groups such as Diabulimia Helpline provide education, support, and advocacy for diabulimics and their families. Additional information about diabulimia can be found on AACE’s patient awareness website.