Over the past several years, there has been an increased awareness of disordered eating among those with type 1 diabetes. The term diabulimia in particular began its emergence in the popular press in 2007, and since then has been used to identify those individuals with type 1 diabetes who omit insulin in order to lose weight in addition to exhibiting other components of disordered eating practices.  

Studies of older teenagers and young adults have reported that approximately 34 percent of young women aged 16-22 and 40 percent of 18-30 year olds have intentionally omitted insulin.(1,2) 

For individuals who exhibit any of the above warning signs, it is imperative that they collaborate with a team of healthcare professionals, including psychosocial support from an individual with eating disorder and diabetes experience. For those individuals in our clinic with diabulimia, they will have appointments with the endocrinologist and CDE every 4-6 weeks and a therapist at least once weekly. As their CDE, the goal of their appointments with me, in addition to reviewing their insulin doses and blood glucose logs, is to help them form healthier eating habits by making small changes. By reacquainting them with what a serving size actually looks like, providers can help them reduce their overall caloric intake without creating a complicated meal plan. It is important to focus on healthier choices for meals and snacks and to always consume something for breakfast. Creating a realistic schedule for meals will also keep them on track.  While weight remains a big focus for these individuals, it is wise to shift that focus at visits. For all individuals with eating disorders that come to our clinic, we have them face backwards on the scale so they do not have to see the number.

Warning signs include:

•    High blood glucose levels
•    A1C levels >9 percent
•    Unexplained weight loss
•    Distorted body image or concern about weight
•    Frequent urinary tract or yeast infections
•    Fabrication of blood glucose results
•    Secrecy regarding insulin injections/dosing
•    Irregular menstrual cycle for females
The key to successfully achieving their goals is to link it with their motivation. I always have plenty of parents who tell me they remind their teens of the long-term complications of diabetes to motivate them to improve their diabetes control. However, most teens cannot focus that far in the future; their thoughts are on the here and now. Using their present-day motivator can lead them to achieving their goals better. Instead of focusing on eye and kidney damage, they can realize that dosing for meals and blood sugars will help them sleep better, feel less tired, have more time to hang out with friends, help their sports performance, and have less blurry vision so that those who have a license can drive.

Setting small, realistic goals is essential for the individual to actually have some success toward improvement. We are all aware of what is ideal for blood glucose testing and blood glucose goals, but it is important to meet the individuals where they are comfortable. If they are not testing blood glucose at all, a goal of testing 1-2 times per day can help that person to be successful in one aspect of their diabetes care by achieving a realistic goal. A solid collaboration between providers and patients is key to helping patients get through this clinical challenge and help them get back on track with their diabetes self-management.

Article References
1. Rydall AC et al.  New Eng J Med. 1997;336:1849-1854. Disordered eating behavior and microvascular complications in young women with insulin-dependent diabetes mellitus.
2. Stancin et al. Diabetes Care. 1989;12:601-603. Binge eating and purging in young women with IDDM.

To learn about one person’s experience with diabulimia, check out this story here.