By Carly Poynter, AMFT
Diabulimia is the combination of diabetes—“dia”—and “bulimia.” While diabulimia is not a medical diagnosis, this term describes the comorbid diagnosis of an eating disorder and type-1 diabetes. Medical provider refer to diabulimia as ED-DMTI.
Type 1 diabetes is a medical condition—an autoimmune disease. In type 1 diabetes (T1D), the immune system attaches the cells in the pancreas that produce insulin. As a consequence, the body lacks adequate insulin, the hormone that converts energy from food to glucose. Individuals with diabulimia purposefully restrict insulin as prescribed to manipulate their weight.
The term diabulimia is somewhat misleading. Bulimia is a diagnosis characterized by compensatory behaviors such as self-induced vomiting, laxative use, exercise, and other purging behaviors to prevent weight gain from caloric intake. Individuals with diabulimia use restriction of prescribed insulin as a means to “purge” caloric intake through excess glucose. The restriction of insulin—which is needed to convert glucose into a usable form of energy for the body—causes the glucose to be excreted through urine. While restricting insulin is the primary source of weight manipulation, individuals may exhibit several symptoms characteristic of anorexia nervosa, bulimia nervosa, or binge eating disorder.
It is important to note that diabulimia is only one manifestation of the intersection between diabetes and eating disorders. The combination of an eating disorder and diabetes can be very dangerous.
Some of the symptoms of diabulimia that people experience include:
- Unexplained weight loss
- Poor control of blood glucose levels
- Excessive thirst
- Frequent urination
- Episodes of nausea and/or vomiting
- Fatigue and increased sleep
- Increased hunger
- Stunted growth in adolescents
- Recurrent hypoglycemia
- Secrecy around diabetes management
- Anxiety about weight or shape
- Increased interest in food, calories, or dieting
- Various symptoms of disordered eating
Symptoms of disordered eating that may be present might include dieting, binge eating, restrictive eating, refusal or embarrassment of eating around others, preoccupation with body weight and shape, excessive laxative use, self-induced vomiting, and other behaviors to control body weight and shape.
Individuals with diabulimia may refuse medical care or continued medical monitoring due to fear of medical providers confronting them about not taking insulin as prescribed.
Medical Consequences of Diabulimia
Restricting insulin is extremely dangerous, and the medical consequences can be dire. For individuals with type 1 diabetes, withholding insulin causes high blood glucose levels, which will cause detrimental health consequences over time. One of the most severe medical conditions associated with diabulimia is diabetic ketoacidosis, which is when the blood becomes toxic due to the body using fat instead of glucose to fuel the body. Diabetic ketoacidosis is a medical emergency and requires immediate medical attention and often hospitalization due to the risk of coma and death if left untreated.
Other medical consequences of diabulimia include peripheral and autonomic neuropathy (nerve damage characterized by a tingling sensation in the extremities that can be permanent); retinopathy or loss of vision; cardiovascular disease; and kidney failure. These conditions require extensive medical intervention and may be permanent.
In addition to the medical consequences associated with insulin restriction, the individual may be at risk for the panoply of medical consequences associated with eating disorders. Restriction of caloric intake can cause severe malnutrition, which is associated with bradycardia or tachycardia (abnormally low or high heart rate), dizziness and fainting, cardiovascular conditions including sudden cardiac arrest, amenorrhea (loss of menses), osteopenia (bone density loss), and other reductions to bodily functioning.
Self-induced vomiting, laxative use, and other means of purging can cause esophageal tearing, edema, gastrointestinal issues, electrolyte imbalance, tooth decay, and cardiac arrest. The restriction of insulin exacerbates these medical consequences.
How Do I Know If I Have Diabulimia?
If you have diabetes, struggle with frequent and recurrent thoughts about weight loss, and have underdosed insulin in an attempt to lose weight, you may have diabulimia. Additional disordered eating is not necessary but is common among those with diabulimia. Even if you do not experience disordered eating, you may have diabulimia. While the symptoms listed above are common among those with diabulimia, the list is not all-encompassing. If any of the information above resonates with you, seek medical attention and see the resources at the bottom of the page.
What Causes Diabulimia?
While there is no single known cause, several factors seem to contribute to the development of diabulimia. When people develop type 1 diabetes, they often lose weight because they are not extracting the energy they need from the food. Once they start taking insulin, they often gain that weight back. Some people struggle with this and may be tempted to skip doses. Furthermore, someone getting used to self-administering insulin may find it uncomfortable, and be tempted to use less insulin than prescribed.
Additionally, aspects of traditional diabetes management may contribute to the development of an eating disorder. These include:
- Increased emphasis on dietary control of blood sugar, which can lead to a fixation on limiting calories and labeling foods as “good” and “bad.”
- Tracking of blood glucose levels can increase the focus on counting and numbers.
- Control over food choices is encouraged, which can lead to further restriction.
- Recommended limits of carbohydrates may trigger binge eating.
- Some health professionals focus on weight loss and preventing weight gain as a misguided management attempt.
The diagnosis of a chronic medical condition, such as diabetes, may make a person more vulnerable to developing a mental health disorder. The distress, shame, and marginalization may contribute to urges to binge eat and/or increase the “need” to fit in, increasing the likelihood of someone dieting or engaging in eating-disordered behaviors.
Who is Most at Risk?
Eating disorders and eating disorder behaviors are more common in individuals with type 1 diabetes than peers without diabetes (Hanlan et al., 2015). One study found that 31% of adults with diabetes had symptoms of disordered eating. The prevalence of disordered eating increased with body mass index (Watt et al., 2021).
Treatment for Diabulimia
The treatment of diabulimia can be tricky. Traditional treatment for eating disorders, such as residential treatment centers and partial hospitalization programs, designed to treat eating disorders, such as anorexia nervosa and bulimia nervosa, may be less equipped to support individuals with diabetes.
The treatment of diabulimia must include a multidisciplinary team that consists of an endocrinologist, eating disorder physician, nurse, psychotherapist, dietitian, and diabetes educator. All of these professionals should be trained in the treatment of eating disorders. This team should operate with a coordinated and collaborative approach to treat the eating disorder and diabetes concurrently.
Patients often require inpatient care due to medical instability and the significant consequences of diabulimia. These patients will need medical supervision, including blood glucose monitoring, insulin re-introduction and management of adverse reactions, diabetes education, and management and treatment of medical consequences associated with diabulimia.
Dietetically, the patient will require education about diabetes and assistance with developing strategies to increase frequency of meals. It is also important for the patient to understand diabetes and how meals impact diabetes. However, it is imperative that the dietitian practice from a restriction-free perspective, because restriction often triggers increased urges for binge eating and subsequent compensatory behaviors. Some patients may benefit from implementation of insulin pump therapy which may inhibit the urge to restrict insulin (Markowitz et al., 2013).
Psychologically, people with diabulimia benefit from strategies addressing shame, marginalization, and body image issues that maintain diabulimia. Cognitive behavioral therapy (CBT), dialectic behavioral therapy (DBT), and acceptance and commitment therapy (ACT) are often used by psychotherapists to treat eating disorders and chronic medical conditions such as diabetes.
The first-line treatment for adults with an eating disorder is enhanced cognitive behavioral therapy (CBT-E). This is a four-phase model that teaches skills necessary to increase frequency of meals, address dietary restraint, work through maintaining factors, and develop strategies for relapse prevention. While there are many treatment options for individuals with more traditional forms of eating disorders, the options for those suffering with diabulimia are limited.
Get Help for Diabulimia in California
If you or someone you know suffers from Diabulimia in California, we can help. Our therapists can provide psychotherapy and we can work with your medical team and/or provide referrals to doctors and dietitians with whom we frequently work. You can contact us here.
Diabulimia Helpline is a nonprofit organization that provides educational information about eating disorders and diabetes, the treatment of diabulimia, and additional resources for individuals, families, and professionals.
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.
Broadley, M. M., Zaremba, N., Andrew, B., Ismail, K., Treasure, J., White, M. J., & Stadler, M. (2020). 25 Years of psychological research investigating disordered eating in people with diabetes: What have we learnt? Diabetic Medicine, 37(3), 401-408. https://doi.org/10.1111/dme.14197
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
Hanlan, M. E., Griffith, J., Patel, N., & Jaser, S. S. (2013). Eating Disorders and Disordered Eating in Type 1 Diabetes: Prevalence, Screening, and Treatment Options. Current diabetes reports, 10.1007/s11892-013-0418-4. Advance online publication. https://doi.org/10.1007/s11892-013-0418-4
Markowitz, J. T., Alleyn, C. A., Phillips, R., Muir, A., Young-Hyman, D., & Laffel, L. M. (2013). Disordered eating behaviors in youth with type 1 diabetes: prospective pilot assessment following initiation of insulin pump therapy. Diabetes technology & therapeutics, 15(5), 428–433. https://doi.org/10.1089/dia.2013.0008
Watt, A., Ng, A. H., Sandison, A., Fourlanos, S., & Bramley, A. (2022). Prevalence of disordered eating in adults with type 1 diabetes in an Australian metropolitan hospital. Health & Social Care in the Community, 30(4), e974-e980. https://doi.org/10.1111/hsc.13500