Despite increased awareness of eating disorders over the past decade, the eating pathology of individuals is still problematic. As a result, certain unspecified eating disorders have risen. Eating disorders are quite prevalent in adolescents, especially in young women with Type 1 diabetes.

What is diabulimia?

Diabulimia, is a diabetes-specific eating disorder which is characterised as intentional restriction/skipping of insulin dosing as well as food restriction for body image and societal perceptions. Diabulimia is commonly seen in individuals with T1DM. An eating disorder is twice as likely to develop in people with type 1 diabetes. Women are more prone to diabulimia. Individuals with T2DM may suffer from diabulimia. Insulin’s function and pathophysiology, however, may differ. It is important to understand that they may still be at a higher risk of suffering from other eating disorders. 

Diabulimia is a dangerous condition which has not yet been recognised. It has been gaining importance in the medical and psychiatric communities.

Why are individuals with T1DM at a higher risk of diabulimia?

To understand why individuals with T1DM may suffer from diabulimia, it is important to understand the pathophysiology of T1DM and the role of insulin in diabetes management.

The autoimmune condition –  Type 1 diabetes mellitus causes the destruction of the body’s beta cells (they produce insulin). As a result, the body produces less insulin for the management of blood glucose.

Due to lipid catabolism, the body is in a state of DKA (diabetic ketoacidosis). This results in glucose accumulation in the blood (hyperglycaemia).

As a result, a prescribed insulin dose is needed to counteract the blood glucose spike when food is eaten.

What happens when insulin is restricted?

When there isn’t enough insulin, the body cannot effectively process the elevated glucose levels. As a result, it is excreted in the urine.

However, due to the frequent excretion, there is loss of bodily fluids leading to weight loss.

When an individual with T1DM perceives this weight loss to be attributed to fat loss and not fluid loss, he/she is thereby triggered to repeat this pattern.

However, not all individuals with diabulimia may omit insulin for weight reasons, a few other possible reasons could be due to needle phobia, cognitive issues, mood disorders, social anxiety and fear of becoming hypoglycaemic.

How does diabulimia develop?

Diabulimia may stem from a combination of factors both intra-personal and external.
Here are some triggers of diabulimia:

• Being overly conscious of body weight.
  
  
• Calorie tracking.
  
  
• Reading food labels.
  
  
• Sudden weight loss.
  
  
• Feeling ashamed of having and managing diabetes.
  
  
• Inability to maintain a healthy weight.
  
  
• The need to eat to manage hypoglycaemic episodes.     

Warning signs of diabulimia

The common warning signs of diabulimia are characterised as below:

• A constant high in HbA1c (glycosylated haemoglobin).
  
  
• Repetitive hospital admissions for DKA.
  
  
• A strong need to be thin. 
  
  
• Feeling dissatisfied with body image.
  
  
• Eating characteristics overlap with bulimia nervosa.
  
  
• Candida or bladder infections due to hyperglycaemia.
  
  
• Irregular periods/amenorrhoea/late puberty (due to high HbA1c).
  
  
• Not showing up to doctor appointments/inconsistent attendance.
  
  
• Blood glucose monitoring indicates glucose measurement irregularities.
  
  
  

Why is diabulimia serious?

A study has mentioned diabulimia is “The world’s most dangerous eating disorder.” Individuals with diabulimia are at a threefold higher risk of death. A deficiency of insulin can result in elevated blood ketone levels. The ketones cannot pass through the blood-brain barrier. Ketoacidosis can lead to:

• Cerebral oedema
• Heart attack
• Kidney failure
• Dehydration
• Muscle breakdown
• Retinopathy
• Neuropathic complications
• Early mortality

If you or someone you know is facing challenges with diabetes management or eating disorders, please contact a qualified healthcare professional for assistance.

How is diabulimia treated?

Early diagnosis of diabulimia may help prevent serious macrovascular and microvascular complications while also enhancing their quality of life.

Here is the story of Trisha who successfully overcame diabulimia

“Trisha is a 17-year-old student. She was a happy girl and a football player. From the day of diagnosis, Trisha was consistent with her glucose monitoring and insulin. However, as she began university, she became very self-conscious and shy. One day, when members of her football team commented on her diet and body, she felt very demotivated. She immediately associated her looks with her diabetes management.

As time passed, Trisha became very self-conscious and wanted to please others with her appearance. So, she began to skip her insulin injections, avoiding doctor’s appointments. She was ecstatic about her weight loss. However, very soon she had dizziness, fatigue and poor athletic performance. One day Trisha’s mother observed these changes in her and consulted a diabetes specialist. Trisha was to have diabulimia.

In a few months, with the right guidance and support from a multi-disciplinary team, Trisha was able to prioritise her health over social pressures and she learnt to build her relationship with food and take her insulin injections.”

However, it is important to understand that – Breaking the vicious cycle of not taking insulin can be challenging for most individuals. It is easy to specify that speaking to someone can help an individual with diabulimia but the first step to overcoming diabulimia is “acknowledging the fact that he/she may have an eating disorder.”

A multi-disciplinary team comprising of psychologists, dietitians, endocrinologist and eating disorder specialists can provide the best care.Though most endocrinologists are aware of this disorder, most primary health care providers and the general public (family too) need to be educated on this eating disorder. Understanding risk factors and early interventions can reduce future risk for individuals with T1DM.

If you or someone with diabulimia are looking for treatment for diabulimia, we suggest you speak to your general practitioner (GP) for more information on how to overcome diabulimia successfully.


Mayuri,
Dietetic Researcher, Simplyweight