Diabetes and Eating Disorders

Living with Type 1 diabetes can be challenging. There is day-to-day attention on the type and amount of foodyou eat, how much carbohydrate you have at every meal and snack, and how much insulin you need to take. Unfortunately, being weighed frequently and focusing on your weight and what you are eating may lead to concerns about eating and your weight. You may be encouraged to eat less or lose weight in order to have well-controlled blood glucose levels. While this advice may be given with the aim of being helpful, it may cause you to focus even more on what you put in your mouth and the number on the scales. 

Disordered eating occurs on a spectrum from mildly abnormal thoughts and behaviours regarding weight, shape and eating, to more concerning thoughts and behaviours that have consequences on physical and mental health. Disordered thoughts include preoccupation with food, weight, and shape, distortion in body image, over-evaluation of weight and shape in terms of self-esteem, and fear of weight gain. Disordered behaviours include restrictive eating practices, food rules, erratic oral intake, excessive or compulsive eating/exercise, chronic energy restriction, binge eating, inappropriate hydration practices, and inappropriate use of medication (e.g. insulin omission, laxatives, diuretics, prescribed medications, or GLP-1 agonists). 

Even if someone does not meet the diagnostic criteria for an eating disorder, it is of concern if they experience disordered eating, thoughts, or behaviours, as this can negatively impact their physical, mental, and emotional health, and put them at high risk of developing an eating disorder.

What are some signs that I may need more support with my diabetes management?

One sign that you may need more support from your diabetes team, GP, and mental health professional is if you are deliberately taking less insulin than is recommended or perhaps omitting doses of insulin altogether. This behaviour is called insulin misuse. You may have heard it called by other names such as “diabulimia”. Misusing insulin means you are at risk of developing, or have, an eating disorder. Any level of insulin misuse requires medical attention even if it is a behaviour that only happens occasionally, as it does not have to occur frequently to put your health at risk. 

Other signs or symptoms of being at risk of or having an eating disorder include*:

• High HbA1C level
• Frequent hospital admissions for diabetic ketoacidosis
• Avoidance of checking your blood glucose levels
• Neglecting diabetes management tasks including skipping doctors’ appointments
• Use of any eating disorder behaviours such as binge eating, vomiting, using diet pills, or laxative misuse
• A low body weight or having lost a significant amount of weight
• Feeling anxious that you will gain weight when you take your insulin
• Feeling that being thin is more important than having good control of your diabetes
• Having a belief that taking less insulin or omitting insulin is a successful way to control your body weight (when the research actually has shown that this is not the case and people who misuse insulintend to be heavier than people with diabetes that don't misuse their insulin).

* If you have ticked one or more of the above signs, then please reach out to your GP or diabetes health professional for support.

Why are people with diabetes at an increased risk of eating disorders?

There are a number of factors that increase the risk of eating and weight concerns in people with diabetes. These factors include:

• Using food or maladaptive eating behaviours as a way of coping with the diagnosis of diabetes as it may be a stressful life event for you and your family.
• The daily challenge of managing all the tasks related to diabetes such as self- monitoring, taking insulin, and attending medical appointments.
• Weight fluctuations that may occur at the time of diagnosis with type 1 diabetes. These normal fluctuations of weight that occur at diagnosis, or when commencing insulin, may trigger body image concerns and a desire to control your weight. You may be faced with the dilemma that you want to have good control of your diabetes but don’t want to put on weight. This can be very confusing especially if you don't have supportive people to help you.
• The fear of hypoglycemia - this is when blood glucose levels are intentionally kept high in order to avoid episodes of low blood glucose.

Why have I never been asked about insulin misuse?

Despite the prevalence of insulin misuse and eating disorders in people with diabetes, most people have never been asked about these behaviours. This may be because there is a lack of awareness of the problem, or because it is easy for signs of an eating disorder, such as eating less and losing weight, to go under the radar because they might be seen as part of “good diabetes management”. It is recommended that health professionals routinely screen for insulin misuse and eating disorders in people with diabetes.

Where can I get help?

A good starting point is talking to your GP and diabetes care professionals. They are the experts in diabetes and can provide support for you in balancing your eating and insulin doses. It is also a good idea to talk to a mental health professional such as a clinical psychologist who works at an eating disorder clinic, as part of community mental health team, or in private practice. A dietitian with experience in diabetes may also be helpful. Engaging in therapy , such as Cognitive Behaviour Therapy (CBT) may provide a good framework tobuild confidence with diabetes self-management and build skills necessary to manage the emotional impact ofliving with diabetes. A clinician with experience in eating disorders can also help challenge some of the thoughts and beliefs about eating and weight that keep unhelpful behaviours going. If you have also identified that you have a fear of hypoglycaemia, (which may occur separately to or as part of an eating disorder), it is important to seek treatment for this also.

What can I do?

Barriers to accessing treatment may include guilt and shame over using these behaviours, hoping the problemwill go away on its own, perceiving that the problem is not severe enough, or having previously disclosed behaviours but not being taken seriously. These are common concerns in someone with an eating problemthat prevents them asking for help and engaging in treatment. However, the most important thing for you to do is tell someone you trust. 

Aiming to establish a routine of regular eating, self-monitoring, and taking your insulin is the long term goal for your long term health. One small change can make a huge difference in your health, so try to reach out to all the people around you for support, including family, friends, and health professionals. It is hard work having diabetes, but there are lots of people around you that can help support you through it.