Eating Disorders

The pressure to be thin can feel overbearing in our society. Research suggests that eating disorders are probably more common among women with diabetes than women who do not have diabetes. Eating disorders are common among women and girls in the general population. However, those with type 1 are twice as likely to suffer from disordered eating patterns. There is no data on eating disorders in men and boys with type 1 diabetes. However, disordered eating does occur among men and boys in the general population, so don’t ignore warning signs.

Bulimia is the most common eating disorder in women with type 1 diabetes. Among women with type 2 diabetes, binge eating is more common.

Because both diabetes and eating disorders involve attention to body states, weight management, and control of food, some people develop a pattern in which they use the disease to justify or camouflage the disorder. Because the complications of diabetes and eating disorders can be serious or even fatal, responsible, healthy behavior is essential.

Eating disorders are illnesses with a biological basis modified and influenced by emotional and cultural factors. While eating disorders are serious, potentially life threatening illnesses, there is help available and recovery is possible.

Types of Eating Disorders

  • Anorexia (or anorexia nervosa) is an eating disorder centered around an obsessive fear of weight gain. Anorexia involves self-starvation and excessive weight loss. Although anorexia is a psychological disorder, the physical consequences are serious and sometimes life-threatening.
  • Bulimia is characterized by recurrent binge eating (the rapid controlled consumption of large amounts of food). Purging may occur with self-induced vomiting, laxatives, diuretics, insulin omission or reduction, fasting, severe diets, or vigorous exercise.
  • Binge Eating Disorder (also known as Compulsive Overeating) is characterized primarily by periods of uncontrolled, impulsive, or continuous eating beyond the point of feeling comfortably full. While there is no purging, there may be sporadic fasts or repetitive diets and often feelings of shame or self-hatred after a binge.
  • Eating Disorders Not Otherwise Specified (EDNOS) is a range of other disordered eating patterns that doesn't fit the other specific types. These conditions are still serious, and intervention and attention are necessary. EDNOS, or other types of eating disorders, may include:
    • Eating problems or disordered eating with some, but not all, of the characteristics of an eating disorder; for example, people who severely restrict food intake, but who do not meet the full criteria for anorexia nervosa.
    • Chewing food and spitting it out (without swallowing).
    • Bingeing and purging irregularly, such as at times of increased stress.

Warning Signs of Eating Disorders

  • Unexplained increase in A1C Levels
  • Repeated episodes of diabetic ketoacidosis
  • Extreme concerns of body size/shape
  • Excessive exercise and related hypoglycemia
  • Very low-calorie meals
  • An absence of menstruation

Eating Disorders and Pregnancy

Women with eating disorders have higher rates of miscarriage than do healthy, normal women. Also, your baby might be born prematurely, meaning that it would not weigh as much or be as well-developed as babies who are born full term.

Women with anorexia nervosa are underweight and may not gain enough weight during pregnancy. They risk having a baby with abnormally low birth weight and related health problems.

Women with bulimia nervosa who continue to purge may suffer dehydration, chemical imbalances, or even cardiac irregularities. Pregnancy heightens these health risks.

Women who are overweight due to binge eating are at greater risk of developing high blood pressure, gestational diabetes, and overgrown babies. Low birth weight babies are at risk of many medical problems, some of them life threatening.

Your teeth and bones might become weak and fragile because the baby's need for calcium takes priority over yours. If you don't replenish calcium with dairy products and other sources, you could find yourself with stress fractures and broken bones in later years. Once calcium is gone from your bones, it is difficult, if not impossible, to replace it.

Diabulimia

Unexplained weight loss is a symptom of diabetes that often alerts a person that something is wrong.  This, along with other symptoms such as excessive thirst and frequent urination often lead to a diagnosis of diabetes.  Treatment for type 1 diabetes is insulin.  “Diabulimia” is an eating disorder characterized by intentionally withholding insulin to result in weight loss. 

The insulin restriction results in high levels of glucose in the blood that spill over into the urine, leading to the excretion of the calories from glucose. The repercussions can be severe, including dehydration, loss of lean body tissue, and, in extreme cases, diabetic ketoacidosis. 

Diabulimia is shockingly common; as many as a third of women with type 1 diabetes report insulin restriction, with higher levels among those between the ages of 15 and 30. 

Getting Treatment

Once insulin restriction or other disordered eating behaviors become engrained, a cycle of shame, guilt, and other negative feelings can make it difficult to get help and the condition difficult to treat. 

A team-based approach is the gold standard.  The team should include a mental health professional along with other team members such as an endocrinologist, nurse educator, nutritionist, and others as necessary. In very severe cases, hospitalization may be needed until the person is more mentally and medically stable.  Ongoing therapy at least monthly or more frequently with care team members may be needed. 

Personal Story from The Type 1 Diabetes Self-Care Manual by Jamie Wood, MD and Anne Peters, MD

Type 1 Diabetes Self-Care Manual

I Knew How to Play the Game

As a type 1 diabetic from the age of 7, I just knew I was an expert on this disease. I rolled my eyes at countless nurses, endocrinologists, and educators who lectured me endlessly on ways to manage my diabetes...I was invincible. No doctor or nurse or anyone could tell me any differently, especially if they didn’t have to live with it. How dare they? 
My A1C, however, was through the roof. I had multiple retinopathy surgeries to stop the bleeding in my eyes, I only had four toes left, and yet, diabulimia was still strong. I lay in ICU on an insulin drip thinking, “I have got to get out of here and off this drip; I’m getting fatter by the minute.” I was so focused on carbohydrates and food and insulin, all day, every day—but not for the right reasons. I knew how to play the food-medicine game. I could eat anything I wanted and then some, and lose weight. I would live at my threshold, taking the tiniest basal amounts of insulin just to skirt by, exhausted and thirsty. I could hardly function day-to-day. 
I had all these complications and forgot what it meant to “feel good.” I was an angry and sad person. The ignorance of the public, my friends, and some of my family was frustrating and hurtful...
When I was pregnant, I was singularly focused on having a healthy pregnancy, bringing my A1C down to 5.6. But after Emmalyne was born, I didn’t want to gain weight, so I started cutting insulin again. 
I was sacrificing my entire life to diabulimia, until my daughter was diagnosed at the age of 2 with type 1 diabetes. I was sick over it. And the comments: “If you just fed her right…” or “Maybe she will outgrow it…” Then it hit me. I cannot let her grow up feeling the same way I did: alone, frustrated, misunderstood, and judged. 
More than anything, I wanted her to enjoy her life, which had just begun, and I wanted to be alive and well enough to get her to adulthood. I wanted to be a great mother but I was too tired to play, too sick to give her all the attention she deserved. She made toes for me out of Play-Doh so I could chase her at the playground. She looked up to me for guidance. Did she think this was her future? 
We were a team. We would fight it together. I would not let her down. Screw this disease and everything it had already taken from me. I refused to let it now take her mother from her.
—Kathlin Gordon, RDN, 40, is a registered dietitian nutritionist.
  • Last Reviewed: August 1, 2013
  • Last Edited: December 7, 2018

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