Diabulimia in Men: The Eating Disorder We Don’t Talk About Enough

When most people talk about eating disorders, the typical image that comes to mind is a young woman struggling with body image.

But eating disorders affect people of all genders. For men living with type 1 diabetes (T1D), there is one particularly dangerous and often unrecognized eating disorder: diabulimia. 

What is diabulimia?

Diabulimia is the practice of intentionally restricting insulin to lose weight. However, it is not an official medical diagnosis, nor is it in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). 

Insulin omission is classified as a purging behavior. People struggling with diabulimia live with both T1D and disordered eating. Eating disorders and disordered eating are mental health issues. 

Someone would typically be diagnosed with bulimia nervosa if insulin manipulation is accompanied by bingeing food, anorexia nervosa if insulin manipulation is combined with restricting calories or Other Specified Feeding and Eating Disorder (OSFED) if their symptoms do not meet the diagnostic criteria for one specific eating disorder. 

How diabulimia affects the body

Because insulin is required for people with T1D to live, withholding it causes glucose to build up in the bloodstream instead of being used by the body’s cells. When blood glucose becomes extremely high, both glucose and calories are excreted from the body through the urine, resulting in rapid weight loss, similar to weight loss experienced at a T1D diagnosis. 

People struggling with diabulimia restrict their insulin usage for carbohydrates consumed, effectively keeping their blood sugar levels dangerously high for quick weight loss. This is an extremely dangerous practice and can be fatal if not treated. The mortality rate for diabetes is about 2.5%, and other eating disorders average a mortality rate of around 6.5%. Someone living with diabulimia has a mortality rate of 34%. 

Yes, men struggle with diabulimia too

Yes. In fact, living with T1D is a risk factor for developing an eating disorder. Having an eating disorder is more common if you live with T1D than in the general population. 

Additionally, both men and women can struggle with diabulimia. While the rates of diabulimia are higher in women (with as many as 40% of young women with T1D reporting insulin restriction), men also struggle with body image and diabetes, resulting in intentional insulin restriction to lose weight.

Some studies show up to 18.5% of men struggle with diabulimia, and many healthcare providers fear the numbers go largely unreported. One study showed that only 15% of men with an eating disorder ever seek treatment. 

Why men are often overlooked

Diabulimia is frequently mentioned in the literature as a condition affecting women with diabetes, but men are not immune. Men often go underdiagnosed due to stigma and the stereotype that eating disorders affect only women. 

Many men experience societal pressure to achieve a certain body type, whether that means being leaner, more muscular or looking more athletic. 

For all people living with diabetes, taking insulin can sometimes be associated with weight gain following diagnosis or periods of improved glucose management. Remember, that means your insulin is working, especially if you’ve lost a lot of weight in the lead up to a diabetes diagnosis. 

Some men may begin skipping insulin doses to prevent weight gain or to lose weight quickly. The stigma surrounding mental health and eating disorders makes it especially difficult for men to seek out help. Many end up suffering in silence, believing that they should be able to manage the problem on their own.

Warning signs to watch for

Recognizing the signs and symptoms of diabulimia can save lives. Symptoms of diabulimia include:

• Consistently high blood glucose levels 
• High A1C
• Rapid and unexplained weight loss
• Frequent episodes of diabetic ketoacidosis (DKA)
• Frequent urination
• Thirst
• Avoiding healthcare provider appointments
• Withholding blood glucose data from others (not allowing others to see CGM data, for example)
• Anxiety about weight gain
• Preoccupation with body image 
• Skipping insulin doses
• Taking less insulin than prescribed
• Avoiding taking insulin injections or doses in front of others
• Mood changes 
• Irritability

People with diabulimia may also exhibit other disordered eating behaviors, including:

• Excessive exercise
• Restricting calories 
• Restricting entire food groups
• Preoccupation with healthy eating
• Bingeing 
• Purging 

Health complications can be serious

Diabulimia is the most dangerous and deadly eating disorder, because chronically high blood sugars affect nearly every organ in the body. 

Repeated insulin restriction can lead to:

• DKA
• Loss of consciousness
• Brain swelling (edema)
• Severe dehydration
• Nerve damage
• Kidney disease
• Diabetic retinopathy and vision loss
• Heart disease
• Increased risk of hospitalization
• Premature death

Many people who have recovered from diabulimia describe years of exhaustion, recurrent infections, chronic dehydration, lethargy, and repeated hospitalizations before they finally sought out help. 

Recovery is possible

Recovery is possible. Like other eating disorders, diabulimia is a mental illness. It affects both the body and the brain.

You can’t tell someone to simply take their insulin and expect them to recover. You must address both the physical and psychological aspects of the condition for a full recovery. 

Talk to your loved ones and healthcare team if you’re struggling with body image and you’re restricting your insulin as a result. Get help immediately. Take the first step in healing yourself by reaching out to someone who can help.

Experts recommend that a treatment team may include:

• An endocrinologist
• A primary care or family physician 
• A mental health professional or therapist with experience in eating disorders
• A registered dietitian familiar with diabetes management
• A diabetes care and education specialist

Treatment may include a combination of medical stabilization, diabetes education, nutrition education, and counseling or therapy. 

In severe cases, inpatient or residential treatment may be necessary to address both the physical and psychological risks to the patient.

You are not alone

Living with type 1 diabetes requires near constant attention to food, insulin, exercise and blood glucose levels. That mental burden takes a toll on mental health. For men, the pressure to appear strong and self-sufficient may make asking for help feel even harder. 

Having honest conversations about insulin omission, body image and eating behaviors can be difficult, but they are essential. Early intervention can prevent life-threatening complications and improve your long-term health. 

Remember: recovery is possible. And you can reclaim the future that an eating disorder has tried to take away. 

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