Diabetes and Eating Disorders

An eating disorder is not a “trend” or a “fad.” An eating disorder is not something to be ignored, with the hope that a person can just “grow out of it.” Eating disorders are serious illnesses that can damage nearly every organ in the body. If left untreated, eating disorders can be fatal ^[1].

Someone with diabetes faces an increased risk of developing an eating disorder ^[2]. Due to this risk, we encourage parents, caregivers and health care professionals to know how to spot the signs of eating disorders in individuals with diabetes and how to find treatment. By knowing the signs of an eating disorder, you can help individuals access the treatment they need. Working together, we can help people heal their relationships with food and their bodies.

Diabetes and eating disorder risk

An estimated 1 in 5 people with diabetes have an eating disorder ^[3].

People with certain types of diabetes are more prone to specific behaviors. For example, those with type 1 diabetes are more likely to engage in purging, which is a way of getting rid of calories with the goal of losing weight. Misusing insulin to control weight is a dangerous form of purging commonly used by individuals with type 1 diabetes ^[2].

Those with type 2 diabetes are more likely to binge eat without purging, especially at night.

Eating disorders impact 30-40% of young females with type 1 diabetes, pointing to the urgency to raise awareness of eating disorders in this population ^[3]. In this piece, we focus on how to help individuals with type 1 diabetes who are showing signs of an eating disorder.

Type 1 diabetes and eating disorders

Type 1 diabetes puts a great deal of stress on the body. There can also be a mental load that comes with type 1 diabetes, as someone must be mindful of the foods they eat and monitor their weight. This can lead to obsessive behaviors and rigid rules — traits that increase the risk of developing an eating disorder ^[3].

Adee Levinstein, MS, RD, LD, CEDS-C, clinical dietitian training specialist with Eating Recovery Center (ERC), shares: “There is a lot of crossover between what some may think are ‘healthy’ behaviors and what are harmful behaviors inspired by diet culture. Many are misled with recommendations to pursue intentional weight loss (often at any cost), which may lead people with diabetes to hyperfixate on food intake and physical activity. This can contribute to the development of an eating disorder.”

When an individual with type 1 diabetes is first struggling with an eating disorder, you may not notice any distinctive signs other than weight loss. Over time, you may notice eating disorder behaviors start to appear. (Eating disorder behaviors may also occur without any noticeable weight loss.) Examples of eating disorder behaviors include:

• A focus on dieting or losing weight
• Body image concerns
• Binge eating
• Rituals around food
• Eating in isolation
• Expressing negative feelings about their size, weight or appearance
• Hoarding or hiding food
• Secretive behaviors around meals, exercise and insulin administration
• Avoiding social gatherings that involve food
• Cutting out certain foods or food groups altogether

Over time, mental health symptoms may also develop. The following signs may also indicate an eating disorder is present:

• Depressed or anxious mood
• Deterioration in academic or work performance
• Failure to attend medical appointments
• Social isolation or withdrawal
• Obsessive-compulsive symptoms
• Self-injury and suicidal thoughts

Caregivers and health care providers are encouraged to pay attention to these signs in individuals with type 1 diabetes. Early recognition is the key to avoiding life-changing, and potentially fatal, complications.

Insulin and type 1 diabetes

People with eating disorders often have a distorted view of weight loss, pursuing it at any cost and via any means necessary. For an individual with type 1 diabetes, this may lead them to start misusing  insulin to lose weight.

To help you understand why insulin misuse is so dangerous, we first discuss how insulin helps those with type 1 diabetes.

• Much of what we eat gets broken down into glucose. Insulin allows our cells to utilize (“uptake”) this glucose.
• Because the pancreas of those with type 1 diabetes has lost its ability to produce insulin, people with type 1 diabetes must administer insulin daily.
• If individuals do not administer insulin as they ingest carbohydrates, they are unable to get glucose into cells and levels of blood glucose rise.
• This becomes an energy crisis at the cellular level given that the glucose is in the blood but unable to be utilized by cells.
• This  often manifests as weight loss.

“Misusing one’s insulin dosage to lose weight is referred to in pop culture as an eating disorder called diabulimia,” Dr. Ovidio Bermudez, MD, FAAP, FSAHM, FAED, F.iaedp, CEDS, senior medical advisor for ERC, explains. “However, this is not a medically recognized term and is not an accurate description.” The best and most descriptive term for this condition is the dual diagnosis of eating disorder and diabetes mellitus type 1 (ED-DMT1).

Insulin manipulation and eating disorders

People with type 1 diabetes can misuse insulin (sometimes referred to as insulin manipulation) as a weight loss tool, which is very dangerous. They may skip doses of insulin, underdose or omit insulin altogether. When this happens, sugar is eliminated from the body via urination instead of being stored as fat or used as fuel. The result? The individual loses weight. They can, essentially, “purge” themselves of calories in this manner.

"This is something people with diabetes know. They clearly understand if they omit, underdose, delay or disable insulin, there's a steep medical price to pay," Dr. Bermudez explains. "But these patients go into a state of denial, where they feel they have it under control."

The concern here is that people with type 1 diabetes, already at a greater risk for eating disorders, may use this method regularly, leading to harmful consequences.

If your loved one or a client with diabetes frequently talks about their weight, has a negative body image, or is fixated on exercise or food, pay attention — and encourage them to seek help, if warranted.

Levinstein adds: “Insulin misuse in those struggling with eating disorders often shows up in dangerously high blood sugar levels, with many potential consequences. The individual may avoid eating carbohydrates altogether, or significantly reduce their intake of carbs in order to reduce the need for medications (including insulin). They may hyperfixate on their food intake and physical activity levels, which may then result in dysfunctional exercise patterns.”

Signs of an eating disorder

An increased risk for eating disorders means an increased risk for serious health complications. So, what are the signs and clinical symptoms of eating disorders that parents, caregivers and professionals can watch for? Look for:

• Slowed or stopped growth in adolescents
• Rapid weight loss
• Increased percentage of hemoglobin A1C levels
• Excessive thirst (polydipsia)
• Increased hunger (polyphagia), which can lead to bingeing
• Frequent urination (polyuria)
• Recurrent episodes of low blood sugar (hypoglycemia)
• Chronic or ongoing lack of insulin with high blood sugar (hyperglycemia)
• Ketones in the urine (ketonuria)
• Recurrent episodes of diabetic ketoacidosis

Hannah Sharkey, RDN, LDN, CEDS, clinical dietitian training specialist with ERC, advises, “Watch for unexplainable weight loss, high blood glucose trends or an increase in A1C level. Be vigilant for repeated episodes of diabetic ketoacidosis, night eating or binge eating, which can occur along with significant food restriction. Also, is the individual viewing foods as being either ‘good’ or ‘bad’ -- especially foods that contain carbohydrates? Many times, these behaviors will all be done in private.”

Eating disorder complications

Living with type 1 diabetes and an eating disorder can lead to a number of complications. Over time, high blood sugar can lead to the damage of small vessels and damage of nerve cells, specifically peripheral nerves.

At the extreme, complications can include:

• Damage to the heart
• Damage to the kidneys
• Damage to the retinas of the eyes
• Damage to peripheral nerves

These complications can affect all patients with type 1 diabetes. For those with eating disorders, the risk increases significantly, with rapid progression of these complications.

A combined diagnosis of diabetes and an eating disorder  is associated with an increased mortality risk when compared to a diagnosis of type 1 diabetes alone. This reflects the importance of diagnosing and treating eating disorders as soon as possible.

Who is most at risk?

Type 1 diabetes is itself a risk factor for eating disorders. This is especially true for pre-teens and teens, who seem to be the most vulnerable [2]. However, eating disorders can present in young adults and adults with type 1 diabetes as well. Overall, eating disorders can affect people at any age, gender and weight.

People with particular personality traits and genetic tendencies, when combined with certain mental health symptoms , environmental factors and a strong cultural influence (such as a thin body as the “ideal”), seem to be more likely to develop eating disorders.

The American Diabetes Association recommends that all individuals with type 1 diabetes be screened regularly for eating disorders by their treatment team.

Learn more about eating disorder causes here.

Eating disorder treatment while managing diabetes

Due to the serious nature of complications and an increased risk of premature death, it is imperative that individuals showing signs of an eating disorder seek help immediately.

A multidisciplinary approach is the most effective way to treat eating disorders. This includes treatment across multiple areas:

• Medical
• Nutritional
• Psychological
• Other support (family, friends, etc.)

For patients newly diagnosed with this condition, hospitalization may be necessary due to the high risk of medical and psychiatric complications and high mortality risk.

Our approach to treatment

ERC offers a sophisticated protocol to provide quality care for patients with type 1 diabetes based on continuously evolving practices that address the needs of those suffering with these serious conditions.

The treatment team follows an "assume then resume" approach, meaning:

1. First, the treatment team takes over the responsibility of diabetes management (counting carbohydrates, checking blood sugars, calculating dose of insulin and administering insulin).
2. Next, the control is gradually transferred over to the patient — once the patient has demonstrated the willingness and ability to manage this well and consistently.
3. Co-occurring mental health concerns (depression, anxiety) and eating disorder behaviors (excessive exercise, purging) are addressed in treatment. Family involvement is also incorporated throughout the treatment process.

Nutrition support at ERC

We help individuals find peace with food and their bodies. We offer supportive structure and meal planning that focuses on balance, flexibility and a wide variety of foods. Our program is weight-inclusive, and we believe that all foods fit.

Here at ERC:

• Individuals plan their meals with a registered dietitian each week. Adults select their own menus and caregivers select menus for kids and teens.
• Our care team is there to support individuals in the moment during meals and snacks.
• We also work closely with caregivers to provide the education and tools they need to support their loved one’s long-term recovery.

Dr. Bermudez offers hope for all individuals struggling with these issues, saying, “I have seen many young people regain focus, resume appropriate management of their diabetes and recover their health, happiness and engagement with a meaningful life. However, for those where this is left unaddressed, the consequences can be devastating. There is hope.”

A note for dietitians

As outpatient dietitians, you play a key role in supporting clients with type 1 diabetes and eating disorders. As you know, adequate nutrition is necessary to help the brain and body repair the damage caused by the eating disorder. We would love to partner with you to support your clients by providing you with education, resources and support.

Learn more about our nutrition approach to eating disorder treatment here.

Long-term support is necessary

Since ongoing insulin management must continue after treatment ends, the patient will need to return to the care of local endocrinologists — ideally those that understand the pathology of type 1 diabetes and eating disorders. Unfortunately, eating disorder relapses can occur, possibly even frequently.

In recovery, ongoing support from family, friends and health care providers will be crucial, with collaboration from outpatient eating disorder professionals and diabetes care professionals.

Learn more about eating disorder treatment here.

Clinically reviewed by Jillian Moshay, MD, CEDS, in April 2024.

Related Reading

• What Is Diabulimia?
• Nutrition in Eating Disorder Treatment
• Types of Eating Disorders