Can Type 1 Diabetes Management Contribute to an Eating Disorder?

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This guest post was written by Eloize Kazmiersky. Eloize graduated has a BSc Nutrition degree from the University of Nottingham and is due to begin an MSc Dietetics degree in Ulster University in September 2020. She is particularly interested in eating disorders and the psychology behind eating behaviours. You can follow Eloize on Instagram @eloize_nutritional_baker

Photograph of Eloize Kazmiersky (Bsc Nutrition)

Diabulimia is an eating disorder (ED) present only in individuals affected with type 1 diabetes (T1D).

This is characterised by consciously omitting to inject insulin in order to lose weight (1). It has been found that up to 30% of adolescents with T1D would misuse insulin in order to achieve this (2). EDs most often occur between adolescence to early adulthood, and the prevalence is higher in young people with T1D, especially females.

Studies have found that the prevalence of any ED in the T1D population was 2.6 times higher than in the general population (3).

In fact, some of the very behaviours required for diabetes management may make an individual more prone to an ED. This article will aim to shed light on diabulimia, as well as exploring the potential impact of a low-carb diet as a treatment option for T1D.

What is Type 1 Diabetes?

Type 1 diabetes (T1D) is an autoimmune condition which usually occurs in childhood and represents about 8% of those with diabetes in the UK (4).

An unknown trigger causes the immune system to attack the body, and particularly the cells in the pancreas which produce insulin. 

Insulin is an essential hormone which allows glucose to enter the cells, therefore reducing blood glucose levels. Glucose is a simple sugar and the main form of energy which fuels the human body. Insulin also stimulates the storage of excess glucose in the form of glycogen and fat in the liver and fat tissue. 

Without insulin, no glucose can be taken up by the tissues so this remains in the blood- causing hyperglycaemia (i.e. high blood glucose levels), which in the long-term can lead to a series of health conditions such as damage to the eyes, kidneys and blood vessels.

An acute consequence of little to no insulin is diabetic ketoacidosis — severe acidification of the blood caused by ketones, a consequence of high blood glucose. This is present at diagnosis of type 1 diabetes (T1D) in around 25% of children in the US, German and Austrian studies (5).

The opposite trend, hypoglycaemia, occurs when there is too much insulin present, causing more glucose to enter the cells than needed which leads to severely low blood glucose levels.

Hypoglycaemia (hypo, or ‘a low’) can be very dangerous. Symptoms of hypoglycemia usually start with dizziness and fatigue, but if this is untreated it can lead to convulsions and potentially death. Thankfully, dying from hypoglycemia is very rare these days (6). 

What is Diabulimia?

Diabulimia involves administering less insulin than the required dose in order to lose weight.

This is a fusion of the words ‘diabetes’ and ‘bulimia’. Diabulimia is not directly related to the eating disorder (ED) bulimia nervosa, apart from the common desire to lose weight. Bulimia nervosa involves purging (i.e. making oneself vomit, use of laxatives or excessive exercise etc.) after eating uncontrollably in a short timeframe. However, some professionals consider omitting insulin to be a form of purging when diagnosing diabulimia (7).

This is an extremely dangerous practice that results in chronic hyperglycaemia (high blood glucose levels) — the long-term consequences of which have been mentioned above. 

Several studies demonstrate the long-term effects of diabulimia.

An 11-year follow-up study with 234 women with T1D showed that those who restricted insulin had a threefold increased risk of mortality and the average age of death was 13 years earlier. Kidney damage and foot issues were also more common in insulin restrictors.

Women who died in this study reported more ED symptoms than other study participants (8). Little data exists unfortunately regarding EDs and diabulimia in men and older adults who have T1D.

The prevalence of diabulimia is high within the T1D population. For example, a study which included 211 people with T1D found that 60.2% of the sample met the criteria for diabulimia in one study (9). Similarly, an older study which included women with T1D found that 31% of the sample reported previously omitting insulin in order to lose weight in another (10).

What Treatment Options Are There For Diabulimia?

Treating diabulimia can be very difficult, as glycaemic control needs to be taken into account. As with the treatment of all types of EDs, outcomes improve when an individual receives medical, psychological and nutritional support (11). 

Some of the most effective treatment approaches which are used alongside nutritional support include cognitive behavioural therapy (CBT) which aims to tackle diabetes-related thoughts and the medical treatment of depression, where appropriate (12).

Carb-Counting and Diabulimia

It has also been shown that women with T1D have a twofold higher risk of developing an ED compared to non-diabetic women aged between 15-30 years old (1).

This may be related to the nature of the management options for maintaining optimal blood glucose levels for a patient with T1D. 

Carb-counting is a common management option for those with T1D.

This involves counting the carb content of food which is about to be consumed so that the insulin dose needed can be more accurately calculated.

Therefore, those with T1D who use this method must constantly pay attention to how much and what kind of food they are consuming. 

Carbohydrate-rich foods require insulin as they spike blood glucose, but at different rates depending on the type of carbohydrate (hereafter carb): 

  1. Simple carbs like sugar, juice, sweets, syrups etc.
  2. Or complex carbs like pasta, bread, rice, starchy vegetables etc. 

Simple carbs spike blood glucose very fast, usually within 10-15 minutes and are used to treat a hypo as sugar is required quickly in order to increase blood glucose levels. Complex carbs require insulin as well but will increase blood sugar over the course of several hours, as they need more time to be digested (13). A meal high in fats and protein will steadily increase blood glucose rather than spike it, as these slow gastric emptying. Some amino acids contained in protein can increase blood glucose similarly to carbs— however, the effects of these foods vary individually (14). 

Matching insulin dose to the amount of carbs consumed is crucial to maintain healthy blood glucose levels.

This is done using ratios which change depending on the time of day. For example, a breakfast ratio could be 1 unit of insulin for 2g of carbs. This means that if a person with T1D ate 30g of carbs for breakfast, they would need to inject 15 units of insulin (30:2=15). This is necessary for each meal of the day, but these ratios can change depending on exercise, alcohol, emotions, hormones and more. These ratios are devised and updated on an individual basis with support from diabetes-specialist healthcare professionals.

Therefore, correctly understanding the nature of the food consumed and calculating the right amount of carbs to dose insulin properly is essential. However, this can trigger an obsessive focus with food and the nutrients they contain in some cases.

Low-Carb Diets and Diabulimia

Low-carb and ketogenic diets are gaining popularity in the general public, as well as among those with T1D. The keto diet is an extremely low-carb diet as outlined in this article

In the past, low-carb diets were used to treat T1D before insulin was discovered. Research is limited in this area, but a few studies have come to the conclusion that low-carb and keto diets may improve overall blood glucose control in T1D treatment and reduce the number of injections needed. However, the keto diet was also associated with more hypos and worsened cholesterol levels, which is very worrying (15).

There are a couple of setbacks to these restrictive diets as an option to manage T1D.

Restricting a macronutrient could further fuel the ED mindset and perpetuate fear around food, perhaps worsening diabulimia in some individuals.

A case series demonstrated that low-carb diets in children with T1D were associated with growth deficits, fatigue, and a higher risk of heart disease (15). This diet is also hard to follow, as most delicious foods contain carbs!

It is important to highlight that reputable organisations do not support the use of low-carb diets in the management of T1DM.

For example, Diabetes UK states that “At the moment, there is no strong evidence to say that a low-carb diet is safe or effective for people with type 1 diabetes” (16).

Courses such as DAFNE (Dose Adjustment For Normal Eating) empower people with T1D to have the correct knowledge in order to independently adapt their insulin, and stay in control of their diabetes. Their motto is ‘eat what you like and like what you eat’- very much to the encounter of restrictive diets (17).

Low-carb diets are successful in improving blood glucose management overall, but are not sustainable long-term, and can have negative physical and emotional consequences. However, more research is required to provide a representative overview of the consequences of low-carb diets. Check out this article for more information about the pros and cons of low-carb diets,  

Other Possible Triggers For Diabulimia

Hypos can also occur at any time, day or night, and need to be treated accurately, which means drinking or eating even when one is not hungry — a potential ED trigger. Treatment needs to increase blood glucose back into the optimal range, but not too much for fear of hyperglycaemia, as this will require ‘unnecessary’ insulin (15). A potential additional injection can lead to weight gain and perhaps explains the significant difference in women with T1D versus unaffected women. On average, women with T1D are 6.8 kg heavier compared to unaffected women (7).  

This increase in weight due to insulin is more common in women with T1D. This can lead to self-esteem and body image issues because of social comparison and beauty ideals.

Frequent doctor’s visits also mean additional attention paid to maintaining a healthy weight, which is another potential ED trigger (15). 

Conclusion:

Diabulimia is a serious eating disorder which is worryingly common among those with T1DM. This may be related to management options for T1D which increase the focus on weight and nutrition.

Low-carb diets are not recommended in the management of T1D and following a restrictive diet like this may increase the risk of diabulimia further.

T1D is a marathon one is forever training for, and each individual requires a different programme to win. However, it seems that more psychological support for those with T1D is needed in order to avoid the harmful impact of diabulimia.

References

  1. Chelvanayagam, S. and James, J. (2018) What is diabulimia and what are the implications for practice? British Journal of Nursing 27(17).
  2. Shaban, C. (2013) Diabulimia: mental health condition or media hyperbole? Practical Diabetes 30(3): pp. 104-105.
  3. 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 13: pp. 909-916.
  4. Diabetes UK (2020) About Type 1 Diabetes [online]. Available at: https://www.diabetes.org.uk/type-1-diabetes [Accessed June 12th 2020].
  5. Pihoker, C., Koves, I.H. and Glaser, N.S. (2011) Pediatric Clinical Care (4th Ed.) Diabetic Ketoacidosis. Mosby, pp. 1124-1130.
  6. Atkinson, M.A., Eisenbarth, G.S. and Michels, A.W. (2014) Type 1 diabetes. The Lancet 383(9911): pp. 69-82.
  7. Young-Hyman, D.L. and Davis, C.L. (2010) Disordered Eating Behaviour in Individuals With Diabetes. Diabetes Care 33(3): pp. 683-689.
  8. Goebel-Fabbri, A.E., Fikkan, J., Franko, D.L., Pearson, K., Anderson, B.J., Weinger, K. (2008) Insulin Restriction and Associated Morbidity and Mortality in Women with Type 1 Diabetes. Diabetes Care 31(3): pp. 415-419.
  9. Deiana, V., Diana, E., Pinna, F., Atzeni, M.G. et al. (2016) Clinical features in insulin-treated diabetes with comorbid diabulimia, disordered eating behaviours and eating disorders.  European Psychiatry 33: p. 81.
  10. Polonsky, W.H., Anderson, B.J., Lohrer, P.A., Aponte, J.E., Jacobson, A.M., Cole, C.F. (1994) Insulin Omission in Women With IDDM. Diabetes Care 17(10): pp. 1178-1185.
  11. National Institute for Health and Care Excellence (NICE) (2017) Eating disorders: recognition and treatment (NG69). NICE Guideline.
  12. Chawathay, K. and Ford, A. (2016) Cognitive behavioural therapy. InnovAiT 9(9): pp. 518-523.
  13. Maughan, R. (2013) Carbohydrate metabolism. Surgery 31(6): pp. 273-277. 
  14. Sun, L., Ranawana, D.V., Leow, M.S.K., Henry, C.J. (2014) Effect of chicken, fat and vegetable on glycaemia and insulinaemia to a white rice-based meal in healthy adults. European Journal of Nutrition 53: pp. 1719-1726. 
  15. Staite, E., Zaremba, N., Macdonald, P., Allan, J., Treasure, J., Ismail, K., Stadler, M. (2018) ‘Diabulimia’ through the lens of social media: a qualitative review and analysis of online blogs by people with Type 1 diabetes mellitus and eating disorders. Diabetic Medicine 35(10): pp. 1329-1336. 
  16. Diabetes UK (2017) Low-carb diets position statement for professionals [online]. Available at: https://www.diabetes.org.uk/professionals/position-statements-reports/food-nutrition-lifestyle/low-carb-diets-for-people-with-diabetes. [Accessed June 26th 2020]. 
  17. Bolla, A.M., Caretto, A., Laurenzi, A., Scavini, M., Piemonti, L. (2019) Low-Carb and Ketogenic Diets in Type 1 and Type 2 Diabetes. Nutrients 11(5): p. 962.

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