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There’s lots to learn about diabetes, eating disorders, and how they interact. Explore the sections below to find out more.

diabulimia/ED-DMT1

anorexia in diabetes

osfed/ednos in diabetes

binge eating in diabetes

quick facts

diabulimia/ed-dmt1

what is diabulimia or ed-dmt1?

‘Diabulimia’ is not an official diagnosis, however it is a well-understood term within the diabetic community for omitting or restricting insulin doses for the purpose of weight control.

  • An individual with diabetes may struggle with any type of eating disorder 1
  • Diabulimia is also known as ED-DMT1, or ‘Eating Disorder-Diabetes Mellitus Type 1’ 1
  • Diabulimia or ED-DMT1 is extremely dangerous, even in its’ most ‘mild’ forms, and can cause devastating physical and psychological consequences 2
  • Eating disorders (EDs) in T1DM have high mortality and morbidity rates compared with the general population 2
  • Research suggests that 30-40% of females with Type 1 Diabetes Mellitus (T1DM) restrict insulin to control weight 2, 3
  • Early detection of disordered eating in people with diabetes and referral to appropriate members of a multi-disciplinary team (MDT) is crucial for improved health outcomes in this vulnerable group 4

how does diabulimia/ed-dmt1 affect diabetes management?

  • The effects of any eating disorder on blood glucose management in T1DM is profound 5
  • Insulin restriction can result in Diabetic Ketoacidosis (DKA), a potentially fatal acute complication of T1DM 5
  • Diabetes complications may be accelerated in individuals who restrict insulin, particularly retinopathy 3, 5
  • Mortality rates are higher in individuals with diabulimia/ED-DMT 3,5
  • Diabetes-related hospitalisations are more common in those who restrict insulin 6

what signs and symptoms should i watch out for?

  • Weight loss or fluctuating weight
  • Consistently elevated HbA1c levels
  • Diabetic Ketoacidosis (DKA)
  • Diabetes-related hospitalisations
  • Early onset and acceleration of diabetes complications
  • Fluctuating blood glucose levels
  • Increased number of infections or slow-healing infections
  • Extreme concerns about body weight and image, self-criticism
  • Change in eating patterns (restricting or binging)
  • Extreme thirst and going to the toilet often
  • Fatigue, pale skin 
  • Dry skin and dehydration
  • Electrolyte abnormalities
  • Low mood
  • Thin hair
  • Avoiding appointments

(This section has been adapted from references 1-4)

 

anorexia nervosa in diabetes

what is anorexia nervosa?

Anorexia Nervosa (AN) is characterised by:

  • A body weight at, or above 85% of expected weight for age and height 7, 8
  • Intense fear of gaining weight 7, 8
  • Disturbance of how one’s body weight or shape is perceived 7, 8
  • Denial of low body weight 7, 8
  • Anorexia Nervosa is characterised into two sub-types; Restrictive and Binge/purge subtype 7, 8    

how does anorexia affect diabetes management?

  • Insulin restriction to induce ketosis as a means of weight loss may be a feature of AN 1
  • In AN, binge/purge subtype, insulin restriction may be used as purging method, resulting in hyperglycaemia, ketosis, or Diabetic Ketoacidosis (DKA) 1
  • AN in Type 1 Diabetes Mellitus (T1DM) has a mortality rate as high as 34.6 % 9
  • Individuals may restrict food, leading to recurrent and severe hypoglycaemia 10
  • Low body weight may lead in a reduction of insulin requirements 10
  • Ketones may be present with normal blood glucose levels in the case of carbohydrate restriction/starvation 11

what signs and symptoms should i watch out for?

  • Recurrent hypoglycaemia
  • Unexplained DKA
  • Diabetes- related hospital admissions
  • Dehydration
  • Extreme thirst, going to the toilet often (in the case of insulin omission)
  • Extreme concerns about body and weight
  • Early onset and acceleration of diabetes complications
  • Low body weight
  • Hypothermia (low body temperature)
  • Fatigue
  • Anaemia
  • Hypotension (low blood pressure)
  • Dizziness/fainting
  • Extreme weight loss
  • Amenorrhoea (loss of menstrual cycles)
  • Food rituals, for example, cutting food into tiny pieces, eating from the same plate
  • Lanugo (growth of fine hair on the body)
  • Osteoporosis
  • Thin hair, dry skin and brittle nails

           (This section has been adapted from references 1-4 and 7-8)       

 

bulimia nervosa in diabetes

what is bulimia nervosa?

Bulimia Nervosa is characterised by:

 

  • Recurrent episodes of binge eating followed by compensatory behaviours to avoid weight gain 7-8
  • These behaviours have occurred at least once a week for a minimal period of 3 months to reach diagnostic criteria 7-8
  • Binge eating is eating a quantity of food that is larger than what most people would eat in a similar time frame under similar circumstances. Those with BN feel out of control during this period, as though they are unable to stop eating 7-8
  • Compensatory behaviour can be non-purging in nature (for example, excessive exercise or fasting) and/or purging in nature (self-induced vomiting, laxative or diuretic use, or insulin omission) 7-8

how does bulimia nervosa affect diabetes management?

Bulimia greatly affects diabetes management, and an individual living with diabetes and bulimia may struggle with:

 

  • Fluctuating blood glucose control as the binge-purge cycle repeats itself 10
  • Binges may be high in carbohydrates, initially raising blood glucose levels 10
  • Dyslipidaemia and hyptertension have been found to be more common in T1DM with Bulimia Nervosa than without 10
  • HbA1c values have found to be higher in T1DM with BN than without 10
  • Both binge eating and compensatory measures may make it difficult to gauge how much insulin is required 1, 10
  • All compensatory measures (vomiting, excessive exercise, fasting, misuse of medications) can affect glucose levels, making diabetes management challenging 1, 10
  • Insulin omission may be a method of purging as in the case of diabulimia. This can result in Diabetic Ketoacidosis (DKA), a potentially fatal acute complication of diabetes resulting from low levels of insulin circulating in the body 8
  • An individual with BN may be slightly underweight, of normal weight or overweight, making it difficult to detect 7

what signs and symptoms should i watch out for?

  • Fluctuating blood glucose control
  • Repeated DKA or diabetes-related hospital admissions
  • Dehydration
  • Extreme thirst, going to the toilet often (due to hyperglycaemia)
  • Extreme concerns about body and weight
  • Early onset and acceleration of diabetes complications
  • Fluctuations in weight
  • Hoarding food
  • Episodes of over eating
  • Swollen cheeks
  • Sore throat
  • Electrolyte abnormalities
  • Scars on back of knuckles from self-induced vomiting
  • Discolouration or staining of teeth, erosion of enamel
  • Disappearing after eating

           (Adapted from references 1-4, 7, 10)

ednos/osfed in diabetes

what is ednos or osfed?

Previously known as EDNOS (Eating Disorder Not Otherwise Specified), OSFED (Other Specified Feeding or Eating Disorder) is a term used to describe eating disorders which cause clinically significant psychological and physical distress, but do not meet the criteria for other feeding or eating disorders. OSFED is just as dangerous especially with diabetes, but may be “atypical” in nature. Some examples include:

  • A person who meets all the criteria for anorexia nervosa, except that the individual’s weight is in the “normal” range, in spite of significant weight loss 8
  • All the criteria for bulimia nervosa are met, except the duration of the disordered eating behaviour is less than 3 months, or at a frequency of less than once per week 8
  • An individual uses compensatory behaviours after eating small or normal amounts of food (laxatives, insulin omission, self-induced vomiting etc) 8
  • Chewing and spitting out food 8

how does ednos or osfed affect diabetes management?

  • Individuals with diabetes who restrict insulin (diabulimia) and neither have a low body weight, nor binge-eating features may fit into this criteria
  • Features of anorexia, bulimia, diabulimia and/or binge eating disorder may be present 8
  • Frequent or severe hypoglycaemia may be present 10
  • Hyperglycaemia or DKA (Diabetic Ketoacidosis) may be present if insulin is omitted 10
  • Individuals may be slightly underweight, ‘normal weight’ or overweight, making it difficult to detect 7  

what signs and symptoms should i watch out for?

A combination of all signs and symptoms from all eating disorders, including diabulimia or ED-DMT1 may be present in an individual with EDNOS/OSFED. Examples may include (but are not limited to):

  • Recurrent hyper or hypoglycaemia
  • Fluctuating glycaemic control
  • Fluctuating weight
  • Binge eating
  • Restricting food
  • Purging behaviour including vomiting, insulin omission, compulsive exercise, medication abuse
  • Fatigue, dry, pale skin

         (Adapted from references 1-4, 7-8)

binge eating disorder in diabetes

what is binge eating disorder?

Binge eating disorder (BED) is defined as:

  • Recurrent episodes of consuming an amount of food most people would consider “large” within a defined period of time 8
  • The binges are similar to that described in BN, but no compensatory measures are used 8
  • Episodes occur at least once weekly over a period of 3 months or longer 8

 

A person with BED feels out of control during binges, and experiences at least 3 of the following:

  1.  Eating very rapidly 8
  2.  Feeling uncomfortably full 8
  3.  Eating alone because of embarrassment and/or
  4.  Feelings of guilt, disgust and remorse afterward 8

how does binge eating disorder affect diabetes management?

  •  BED may affect patients with any type of diabetes
  •  BED is the most common eating disorder in individuals with Type 2 diabetes 12
  •  Binges often have high sugar/carbohydrate content, causing a peak in blood glucose levels 12
  •  A person with diabetes and BED may find it difficult to adjust insulin doses according to food intake during binges due to the ‘out of control’ and impulsive nature 8, 12
  •  Where weight gain or yo-yo dieting is present, insulin needs may change 12
  •  Someone with BED can be of any weight, but are often ‘normal’ weight, overweight or obese 13

what signs and symptoms should i watch out for?

  • Eating alone
  • Hyperglycaemia (high blood glucose levels)
  • Eating when not hungry
  • Feeling out of control
  • Hoarding food
  • Weight gain, obesity
  • Hypertension (high blood pressure)
  • Cardiovascular disease

         (Adapted from references 8, 11, 12)

diabetes and eating disorder facts

  • Factors contributing to the high rates of a dual diagnosis of T1DM and an eating disorder include biological and genetic vulnerability, trying to follow the cultural ‘ideal’ of thinness, increased BMI, depression, perfectionism, and low self-esteem 1
  • Eating disorders are at least twice as common in women with diabetes than in their peers 10
  • Small, achievable goals and working within a MDT health care team are helpful in the management of diabetes and eating disorders 14
  • Studies show that up to 30-40% of young women with type 1 diabetes omit insulin for the purpose of weight control 10
  • The ‘preferred’ means of weight control in people with type 1 diabetes has been shown to be insulin omission and/or underuse of insulin. However, not all people with diabetes and an eating disorder eating fit this profile 1, 10, 12
  • The co-occurrence of diabetes and an eating disorder results in more frequent hospital admissions, poorer glycaemic control, and increased morbidity and mortality rates 1-4
  •  Some researchers suggest that diabetes and eating disorders both involve close attention to food, weight, health, numbers, and body issues 1-4, 10
  • Approximately 10% of those suffering from eating disorders are male 15
  • Those with type 1 diabetes are likely to have a higher BMI than their peers without diabetes due to insulin therapy. Weight loss is a common symptom of untreated type 1 diabetes prior to diagnosis. Commencing on insulin treatment can lead to rapid weight gain initially 14, 16
  • Individuals with diabetes are more likely to develop depression, a risk factor for developing an eating disorder 17
  • Early detection and management of disturbed eating behaviour in diabetes is crucial to greater health outcomes 18
references
1. Deiana, V., Diana, E., Pinna, F., Atzeni, M., Medda, F., Manca, D., & Carpiniello, B. (2016). Clinical features in insulin-treated diabetes with comorbid diabulimia, disordered eating behaviors and eating disorders. European Psychiatry33(8) doi:10.1016/j.eurpsy.2016.01.029

2. Wisting, L., Froisland, D., Skrivarhaug, T., Dahl-Jorgensen, K., & Ro, O. (2013). Disturbed eating behavior and omission of insulin in adolescents receiving intensified insulin treatment. Diabetes Care, 36(11), 3382-338

3. Colton, P., Olmsted, M., Daneman, D., Farquhar, J., Wong, H., Muskat, S., & Rodin, G. (2015). Eating disorders in girls and women with type 1 diabetes: A longitudinal study of prevalence, onset, remission, and recurrence. Diabetes Care38(7), 1212-1217. doi:10.2337/dc14-2646

4. Philpot, U. (2013). Eating disorders in young people with diabetes: Development, diagnosis and management. Journal Of Diabetes Nursing17(6), 228.

5. Davidson, J. (2014). Diabulimia: how eating disorders can affect adolescents with diabetes. Nursing Standard29(2), 44-49.

6. Diabetics With Eating Disorders (2010). Diabetes and DKA in England’s primary care trusts: A study into the prevalence of diabetes, the costs and the admission rates of diabetic ketoacidosis in England’s primary care trusts November 2010. London: Author

7. Harrington, B. Jimerson, M., Haxton, C., & Jimerson, D. (2015). Initial evaluation, diagnosis, and treatment of anorexia nervosa and bulimia nervosa. American Family Physician, 91(1), 46-52

8. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.

9. Nielsen, S., Emborg, C., & Molbak, A. (2002). Mortality in concurrent type 1 diabetes and anorexia nervosa. Diabetes Care, 25(2), 309-312.

10. Scheuing, N., Bartus, B., Berger, G., Haberland, H., Icks, A., Knauth, B., & … Holl, R. W. (2014). Clinical characteristics and outcome of 467 patients with a clinically recognized eating disorder identified among 52,215 patients with type 1 diabetes: a multicenter German/Austrian study. Diabetes Care37(6), 1581-1589 9p. doi:10.2337/dc13-2156

11. McPherson, P. (2016). Ketone Bodies. Encyclopedia Of Food And Health, 483-489. doi:10.1016/B978-0-12-384947-2.00408-6

12. Çelik, S., Kayar, Y., Önem Akçakaya, R., Türkyılmaz Uyar, E., Kalkan, K., Yazısız, V., & Yücel, B. (2015). Psychiatric–Medical Comorbidity: Correlation of binge eating disorder with level of depression and glycemic control in type 2 diabetes mellitus patients. General Hospital Psychiatry37116-119. doi:10.1016/j.genhosppsych.2014.11.012

13. Dingemans, A., & van Furth, E. (2012). Binge eating disorder psychopathology in normal weight and obese individuals. International Journal Of Eating Disorders45(1), 135-138 4p. doi:10.1002/eat.20905

14. Balfe, M., Doyle, F., Smith, D., Sreenan, S., Conroy, R., & Brugha, R. (2012). Dealing with the devil: weight loss concerns in young women with type 1 diabetes. Journal of Clinical Nursing, 22(13-14), 2030-2038
15. National Eating Disorders Association (2015). Research on males and eating disorders. Retrieved from https://www.nationaleatingdisorders/research-males- and-eating- disorders
16. Merwin, R., Dmitrieva, N., Honeycutt, I., Moskovich, A., Lane, J., Zucker, N., & Kuo, J. (2015). Momentary predictors of insulin restriction among adults with type 1 diabetes and eating disorder symptomatology. Diabetes Care, 38(11), 2025-2032 8p. doi:10.2337/dc15-0753

17. Johnson, B., Eiser, C., Young, V., Brierley, S., & Heller, S. (2013). Prevalence of depression among young people with Type 1 diabetes: A systematic review. Diabetic Medicine, 30(2), 199-208

18. d’Emden, H., McDermott, B., Gibbons, K., Harris, M., & Cotterill, A. (2015). Choosing a screening tool to assess disordered eating in adolescents with type 1 diabetes mellitus. Journal of Diabetes and its Complications, 29 (1), 2-4

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