Diabetes and Eating Disorders

Living with Type 1 diabetes can be challenging. There is day-to-day attention on the type and amount of food you eat, how much carbohydrate you have at every meal and snack, and how much insulin you need to take. Unfortunately, being weighed frequently, and focussing 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 what the scales say. Research has shown that there is a difference between healthy management of diabetes, where some attention is paid to food and body weight, versus excessive focus on what you eat and weigh, to the point that this becomes more important than anything else, even the long term effects of living with diabetes.

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

A 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, 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;

• The occurrence of any eating disorder symptoms such as binge eating, vomiting or laxative misuse;

• A low Body Mass Index.

• 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 it’s difficult to lose weight and control diabetes at the same time;

• Having a belief that omitting insulin is a successful way to control your body weight [research has shown that this is not the case as people who misuse insulin are heavier than people with diabetes that don't misuse their insulin].

* If you tick one or more of the above items you should talk to your GP or diabetes health professional.

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:

• Developing an eating disorder 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 recommencing 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 unawareness about 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 might work 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 Cognitive Behaviour Therapy may provide a good framework to build confidence with diabetes self-management and build skills necessary to manage the emotional impact of living 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 behaviour 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?

The most important thing for you is to tell someone you trust. Perhaps past experiences of disclosing behavior have been trivialised which makes it difficult to disclose behaviors again. Barriers to treatment may be guilt and shame over these behaviours; hoping the problem will go away on its own; or perceiving that the problem is not severe enough. These are common concerns in someone with an eating problem that prevents than asking for help and attending for treatment.

Aiming to establish a routine of regular eating, self-monitoring and taking your insulin is the long-term goal. Steering a course between structured, sensible eating rather than excessive dieting, or being a “perfect eater” is ideal. Ensure you engage all the people around you including family, friends and health professionals because it is hard work having diabetes, and the more support you have the better.