By Maddie B., Lagniappe Wellness Dietetic Intern

What is an Eating Disorder?
Eating Disorders (ED) are serious mental health disorders that can detrimentally affect physical health if left untreated. Two specific diagnoses, Anorexia Nervosa (AN) and Bulimia Nervosa (BN) are generally well-known and more common diagnoses — and are most commonly associated with fear of weight gain and distorted body image.
Anorexia is characterized by active restriction and control of food intake, while Bulimia presents differently and is commonly recognized by purging behaviors. These behaviors include or can be a combination of self-inflicted vomiting, excessive exercise, or abuse of medications such as laxatives or diet pills, with the intention to lose weight or change one’s body.¹
Eating disorders are unique to each person and can present in a number of ways; it is unrealistic to fit such a complex mental health disorder into two monolithic boxes. A variety of diagnoses have become more prevalent and have contributed to new practice in how eating disorders are treated. Other eating disorder diagnoses that are gaining more awareness include: Binge Eating Disorder, Avoidant-Restrictive Food Intake Disorder, and Other Specified Feeding or Eating Disorder. The emergence of a variety of diagnoses helps to specify the most ideal treatment path for each individual based on how their eating disorder presents and what their individual needs are to promote healing.²
Eating Disorders with Type 1 Diabetes Mellitus (ED-T1DM)
Those living with Type 1 Diabetes Mellitus (T1DM) are at an increased risk for developing an eating disorder due to the constant attention to food and diet that coincides with T1DM management. This attention to food intake, blood sugar levels, and carbohydrate counting can lead to a need to reclaim control in their diabetes and strive for a certain level of perfection in diabetes management.^1,3
People living with T1DM may also experience anxiety or depression associated with living with a chronic disease. The non-clinical term “diabulimia” has been coined for eating disorders that are comorbid with T1DM. Diabulimia is characterized by the intentional neglect or avoidance of insulin treatment with intention to lose or control weight.^3,4 Like any other eating disorder, it can manifest differently in each individual’s behavior. Someone suffering from this condition may still actively eat food, but may restrict their insulin as a form of purging. Others may actively restrict their food and their insulin. Since “diabulimia” has not yet become an official diagnosis, patients may be diagnosed with ED-T1DM, a non-specific diagnosis, or in more extreme cases, may just be classified as neglecting DM treatment, where mental health will not be addressed. The lack of official diagnosis and understanding for this condition leaves many untreated or receiving subpar care for their disorder.⁵ People with T1DM and diabetes-related disordered eating are living with continuously elevated blood sugar levels, which can lead to irreversible physical damage or even death. Diabulimia is not only a mental health disorder, but also an uncontrolled chronic disease, which, in combination, is more detrimental and dangerous and must be treated as such.³

Identifying “Diabulimia”
Due to eating disorders being a multifaceted condition, each person’s symptoms may present differently. Below are warning signs to help identify if your client or loved one may be experiencing “diabulimia”:^3,5

• Increased negligence of diabetes management
• Avoidance of discussion of diabetes management
• Extreme changes in dietary intake
• Isolation from social eating, ex: skipping family meals, eating alone, avoiding eating out
• Irrational fear of low blood sugar levels
• Increased concern with body image
• Avoiding diabetes related appointments
• Increased fatigue
• Testing blood sugar levels in secrecy 
• Obsession with food and/or body weight
• Excessive exercise
• Depression 
• Anxiety

Alongside behavioral changes, there are physical changes that may also help to identify this condition:^3,5

• Excessive thirst
• Frequent urination
• Sudden, unexplained weight loss
• Frequent nausea or vomiting
• Consistent Hemoglobin A1C levels of 9.0 or higher
• Frequent Diabetic Ketoacidosis episodes
• Dry hair, skin, nails
• Extreme fatigue
• Vision complications
• Irregular periods in menstruating people
• Bladder or yeast infections

Health Concerns in the Long Term
In a person with T1DM, without insulin, glucose cannot enter the cells, thus preventing weight gain — this may sound ideal and an easy weight loss solution to the person with the eating disorder. In turn, this person restricting their food or insulin is living with extreme prolonged elevated blood glucose levels. The risks associated are parallel to the risks associated with poor management or neglect of T1DM management and range, from nerve damage, to cardiovascular complications, or even death.^3,4
Individuals with diabulimia may have frequent episodes of Diabetic Ketoacidosis (DKA) a diabetic complication associated with lack of insulin, leading to detrimental, irreversible health effects such as kidney damage, vision loss, or swelling of the brain. Serious nutritional deficiencies and electrolyte imbalances can lead to organ failure.^3,4 The combination of a mental health disorder with a chronic disease like Diabetes increases the danger of this eating disorder and cannot be treated in the same manner that health professionals treat Anorexia or Bulimia.3 
Seeking Treatment and the Importance of Multidisciplinary Support
A multidisciplinary team is the ideal treatment structure for a person with an eating disorder. This team usually includes a physician, a registered dietitian, and a mental health specialist. The unique diagnosis of an eating disorder co-occurring with T1DM should include a treatment team that is just as specialized as the diagnosis at hand. A successful treatment for diabulimia must reflect both mental health support and physiological treatment. While the ideal physician would specialize in diabetes care as an endocrinologist, an ideal registered dietitian would be a certified diabetes educator, and a qualified therapist would be one who specializes in eating disorders. Along with a treatment team, a support system of loved ones can significantly enhance the healing process. If a higher level of care is necessary, it is crucial to find a facility that has robust experience in treating diabulimia.³
Advocacy for Awareness and Education
Increasing research and awareness of eating disorders associated with T1DM is extremely important to providing well-rounded care to patients due to the extreme health concerns associated. The non-clinical term “diabulimia” is being embraced more in health professions, and the understanding of this disorder may help to diagnose and treat individuals on a greater scale. Diabulimia is not simply neglect of diabetes management, it is a serious mental health concern that needs to be advocated for and included in the education of health professionals.¹

References:

1. Coleman, S. E., & Caswell, N. (2020, September 23). Diabetes and eating disorders: An exploration of “Diabulimia.” BMC psychology. https://pubmed.ncbi.nlm.nih.gov/32967730/ 

2. Treasure, J., Hübel, C., & Himmerich, H. (2022, January 11). The evolving epidemiology and Differential Etiopathogenesis of eating disorders: Implications for prevention and treatment. World psychiatry : official journal of the World Psychiatric Association (WPA). https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8751578/ 

3. Hall, R., Keeble, L., Sünram-Lea, S.-I., & To, M. (2021, June 13). A review of risk factors associated with insulin omission for weight loss in type 1 diabetes. Clinical child psychology and psychiatry. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8264633/ 

4. Monte Nido. (2022, October 27). Diabulimia: The dangerous condition that doesn’t get enough attention. Monte Nido. https://www.montenido.com/diabulimia-dangerous-condition/ 
5. Diabulimia. National Eating Disorders Association. (2018, February 21). https://www.nationaleatingdisorders.org/diabulimia-5#:~:text=Diabulimia%20does%20not%20have%20a,is%20binging%20then%20restricting%20insulin.