Diabulimia: A Dangerous, Overlooked Eating Disorder
Insulin omission is the core symptom of this deadly eating disorder.
Posted October 17, 2022 | Reviewed by Devon Frye
- The term "diabulimia" is used to describe an eating disorder in which people with Type 1 diabetes use insulin omission to control weight gain.
- Severe consequences of diabulimia could include nerve and organ dysfunction, metabolic disorders, cognitive decline, and death.
- Treating diabulimia requires medical, psychological, and nutritional interventions.
Type 1 diabetes mellitus (T1DM) is an autoimmune condition where the pancreas doesn’t produce its own insulin.1
The body needs insulin to make sure that the food we eat is converted to energy. After eating a meal, carbohydrates are broken down into sugar (glucose), which the body uses for energy.
Glucose isn't useful in the blood, though. It needs to enter the body's cells to be converted to energy. Insulin helps with this process by directing glucose into cells. Once glucose is inside the cells, it is converted into energy for current use or stored for later use.
Because people with T1DM don’t produce insulin, glucose levels stay elevated in the blood and never make it into the cells, causing energy depletion. Therefore, to control blood glucose levels and make sure cells get the energy that they need, people with T1DM must administer insulin daily, which compensates for the body’s inability to produce its own insulin.
In addition to insulin injections, those with T1DM must closely monitor their diet and weight. Weight regulation in T1DM is important because excess weight can contribute to additional health complications (e.g., cardiovascular dysfunctions). Similarly, maintaining a diet of minimal sugars is vital to ensure that the body isn't overwhelmed by glucose.
Because T1DM is most often diagnosed in childhood, these individuals develop a different relationship with food and weight than most kids. From an early age, they realize that they don’t always have “control” over their bodies. They are also taught to strictly monitor their diet and weight.
Eating Disorder Comorbidity: Diabulimia
The unique relationships people with T1DM develop with food and their bodies make it unsurprising that 10 percent of adolescent females with T1DM have an eating disorder, while 14 percent of adolescent females with T1DM have subclinical eating disorder symptoms.2 When adult women are included, up to 60 percent of people with diabetes could have disordered eating symptoms.7
In addition to daily dietary monitoring, another reason people with T1DM are susceptible to disordered eating is insulin-induced weight gain.3 This combination of restrictive eating and weight gain from insulin injections makes those with T1DM, especially adolescent females, vulnerable to eating disorder development.5
Eating disorders for people with T1DM, however, are unique given the hormonal complications of T1DM. Consequently, the term "diabulimia" is used to describe someone with both disorders.11
Notably, diabulimia isn't an official medical diagnosis and the term is somewhat misleading, as this disorder doesn’t always include symptoms of bulimia (e.g., purging food). Rather, diabulimia can include many different eating disorder symptoms (e.g., food restriction); its core symptom, though, is insulin omission.
Insulin omission is a common method people with T1DM use to prevent weight gain.4; 11 One way insulin omission reduces weight is by failing to direct glucose into cells. When glucose doesn’t enter cells, the body needs to look for an alternative energy source to keep itself running.14 In the case of insufficient insulin, the body starts converting fat and muscle into ketones for energy, which in turn reduces weight. The term for this process is diabetic ketoacidosis (DKA).13 Fluid loss during DKA also contributes to weight loss.14
In addition to weight loss, people with diabulimia might omit their insulin intake for perceived physiological benefits. In the brain, insulin functions as an appetite suppressant and, therefore, contributes to feelings of fullness.10 People with eating disorders often avoid feeling full because it causes them great distress.12 Consequently, insulin omission, like food restriction, might reduce unwanted feelings of fullness.
Eating Disorders Essential Reads
Insulin omission might also give people with diabulimia a perceived sense of control over their bodies. Weight regulation is often used by people with eating disorders to gain a sense of control over what otherwise seems like a chaotic existence; put another way, controlling their weight gives them a perceived sense of stability.6 People with T1DM, therefore, might use insulin omission in a similar way.5 As a female with diabulimia acknowledges:
"[My diabetes is the] one thing that I thought controlled me and by not taking insulin I felt like I had the control back."5
The Dangers of Diabulimia
DKA, however, is life-threatening, as too many ketones in the body are toxic. And for those who survive DKA, complications such as severe dehydration, brain swelling, lung dysfunction, kidney damage, mineral deficiency, metabolic disorders, peripheral neuropathy (e.g., nerve dysfunction in feet), and retinopathy (e.g., eye dysfunction) can result.11; 13
Moreover, insufficient insulin can cause oxidative stress and cell death (neurodegeneration) in the brain, which could contribute to cognitive decline, poor motor function,8 and future Alzheimer's disease onset.9
With such extreme, devastating consequences, it is tempting to wonder why people with diabulimia continue to omit insulin. As several female patients with diabulimia explain:
"Something like 'diabulimia'... holds such a powerful grip that I cannot stop myself and get better; I became obsessed with the number on the scale; [I'd] rather die than be fat."5
Therefore, like a traditional eating disorder, diabulimia has the same psychological grip that makes treatment extremely difficult.
Unfortunately, diabulimia is a complicated, heterogeneous disorder, and, therefore, difficult to treat.
In most cases, treatment for diabulimia begins with medical stabilization, which includes fluid and electrolyte replacement, insulin therapy, determining the severity of DKA, and monitoring for health complications, such as cerebral edema (excess brain fluid) and hypokalemia (low potassium).11 Following stabilization, patients begin psychological and nutritional/educational interventions to ensure that they can maintain recovery.
It is important to acknowledge, however, that insulin omission isn't the only strategy people with this disorder use for weight control (e.g., purging). This means that each patient will have different needs and outcomes. Consequently, treatment for diabulimia requires a team of psychologists, medical professionals, and nutritionists with extensive knowledge not only in T1DM, but a range of eating disorders, as well. To better understand how to treat this complex disorder, more research is needed to determine the many, multifaceted consequences of diabulimia.
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2) Jones, J.M., Lawson, M.L., Daneman, D., Olmsted, M.P., & Rodin, G. (2000). Eating disorders in adolescent females with and without type 1 diabetes: Cross sectional study. BMJ, 320, 1563-1566.
3) Russell-Jones, D., & Khan, R. (2008). Insulin-associated weight gain in diabetes - causes, effects and coping strategies. Diabetes, Obesity, and Metabolism, 9, 799-812.
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5) Coleman, S.E., & Caswell, N. (2020). Diabetes and eating disorders: An exploration of 'diabulimia'. BMC, 8.
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7) Deiana, V., Diana, E., Pinna, F., Atzeni, M.G., Medda, F., Manca, D.,...& Carpiniello, B. (2020). Clinical features in insulin-treated diabetes with comorbid diabulimia, disordered eating behaviors, and eating disorders. European Psychiatry, 33.
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9) Hoffman, W.H., Siedlak, S.L., Wang, Y., Castellani, R.J., & Smith, M.A. (2011). Oxidative damage is present in the fatal brain of edema of diabetic ketoacidosis. Brain Research, 1369, 194-202.
10) Schwartz, M.W., Woods, S.C., Porte, D., Seeley, R.J., & Baskin, D.G. (2000). Central nervous system control of food intake. Nature, 404, 661-671.
11) Ruth-Sahd, L., Schneider, M., Haagen, B. (2009). Diabulimia: What it is and how to recognize it in critical care. Dimensions of Critical Care Nursing, 28, 147-153.
12) Schaumberg, K., Reilly, E.E., Gorrell, S., Levinson, C.A., Farrell, N.R., Brown, T.A.,...& Anderson, L.M. (2021). Conceptualizing eating disorder pathology using an anxiety disorders framework: Evidence and implications for exposure-based clinical research. Clinical Psychology Review, 83.
13) Savage, M.W., Dhatariya, K.K., Kilvert, A., Rayman, G., Rees, A.E., Courtney, C.H.,...& Hamersley, M.S. (2011). Joint British Diabetes Societies guideline for management of diabetic ketoacidosis. Diabetic Medicine, 28, 508-515.
14) Fleckman, A.M. (1993). Diabetic ketoacidosis. Endocrinology and Metabolism Clinics of North America, 22, 181-207.