Prevalence & Treatment of Eating Disorders in Type 1 Diabetes
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People with type 1 diabetes are significantly more likely to develop an eating disorder than their non-diabetic peers. Ann E. Goebel-Fabbri, Ph.D. shared her expertise in helping this population achieve recovery. Goebel-Fabbri is also the author of “Prevention and Recovery from Eating Disorders in Type 1 Diabetes: Injecting Hope.”
Presence of eating disorders in type 1 diabetes
The overlap of puberty and common type 1 diabetes diagnosis age add up to a significantly increased risk of developing an eating disorder compared to same-aged peers without diabetes.
- Girls and women with type 1 diabetes (T1D) are 2.4 times more likely to develop an eating disorder than their non-diabetic peers.
- 31 percent of 341 female patients at the Joslin Diabetes Clinic ages 13 to 60 reported omitting insulin in an effort to lose weight.
- People with T1D who restrict insulin are three times more likely to die prematurely.
Aspects of T1D that contribute to the development of an eating disorder include:
- T1D often presents with a symptom of weight-loss. Once insulin therapy has begun, that lost weight is often restored. Patients then associate weight-gain with insulin despite the initial weight-loss being a life-threatening complication of diabetic ketoacidosis.
- Managing T1D involves daily attention to what you eat, portion sizes, memorizing macronutrients (carbs, fat, protein, calories), exercise and weight.
- T1D education often involves messages of “good” and “bad” foods, concepts of restriction around food and “cheating” on bad foods.
How different types of eating disorders present in type 1 diabetes
While every type of eating disorder can be life-threatening, certain aspects of eating disorders in T1D are especially dangerous.
Anorexia in type 1 diabetes
Anorexia is defined as severe calorie restriction often fueled by an intense need for control and a fear of weight gain regardless of how underweight a person may already be.
Signs of anorexia in T1D include:
- Frequent low blood sugars
- Recurring hospitalizations from severe low blood sugars
- Goal A1c level because of frequent low blood sugars
- Associates self-worth with body weight or shape
- Changes in body weight or shape
- Significantly underweight
Anorexia in people with T1D can go undetected until someone close to them spots repeated low blood sugars or notices their body weight is getting dangerously low. Typically, this person’s A1c will look right on target because of hidden chronic hypoglycemia which means it doesn’t raise flags at routine check-ups.
Bulimia / diabulimia in type 1 diabetes
Bulimia nervosa and “diabulimia” are both forms of purging calories. Bulimia is defined by uncontrolled binge-eating followed by several forms of purging the calories—most notably vomiting.
“Diabulimia”—also known as ED-DMT1—is a life-threatening form of purging through omitting insulin doses, putting a person in a nearly constant state of dangerous ketosis or diabetic ketoacidosis (DKA) with blood sugars frequently at dangerously high levels.
Insulin restriction can significantly increase your appetite because your cells are starved for energy, making you feel even more out of control.
“We know that this combination of eating disorders in type 1 diabetes is deadly and incredibly risky,” explained Goebel-Fabbri in her presentation.
Diabulimia can lead to frequent episodes of DKA which is a medical crisis requiring treatment in the intensive care unit (ICU) and can be fatal.
Both bulimia and diabulimia can also include:
- Self-induced vomiting
- Abuse of laxatives, diuretics, enemas, or other medications
- Insulin omission / restriction
- Fasting
- Excessive exercise
Signs of bulimia nervosa and diabulimia include:
- Discreet binge-eating
- Constantly dehydrated
- Constantly tired
- Constantly irritable
- Frequent urination
- Increased thirst
- Rapid weight-loss or weight-gain
- High A1c
- Reluctant to eat in front of other people
- Reluctant to go to routine diabetes appointments
Hoards and hides stores of food - Frequent hospitalizations for severe high blood sugar
- Associates self-worth with body weight or shape
Diabulimia hugely increases a person’s risk of developing long-term complications, including blindness, neuropathy, gastroparesis and kidney failure.
Treatment approaches for eating disorders in type 1 diabetes
Goebel-Fabbri discussed recent research findings on treating eating disorders in people with T1D and why it should be approached differently than those without T1D..
- Traditional cognitive behavioral therapy (CBT) methods are not very effective in treating eating disorders in people with T1D.
- Compared to using CBT to treat eating non-T1D people with eating disorders, the T1D population has overall lower rates of recovery and higher treatment dropout rates.
- Instead, “Acceptance and Commitment Therapy” (ACT) is a type of CBT that’s being tailored for eating disorders and T1D with greater success than other treatment approaches.
- In the “iACt Acceptance and Commitment Therapy” study, 20 of 23 women completed the study with ACT-CBT with a stable weight, and an average reduction in A1c levels from 9.8 to 8.9 percent.
- Establish goals that are gradual, not drastic or sudden, especially in A1c and blood sugar levels. For example, in the first few months strive to reduce an A1c of 14% down to 12%, or blood sugar levels in the 400s down to the 200s.
- Discuss “insulin edema” which is the retention of fluid as a person with T1D begins taking normal levels of insulin again.
- Encourage flexible eating rather than a rigid plan.
- Build a sense of trust and teamwork throughout the pursuit of recovery.
- When supporting a T1D with an eating disorder, avoid shaming and discuss their weight concerns thoughtfully. Weight-gain is often fluid retention from chronic high blood sugars.
What does recovery from an eating disorder with T1D look like?
Goebel-Fabbri defines recovery from an eating disorder with T1D as the following:
- Consistently taking appropriate amounts of insulin
- Not engaging in rigid dieting or over-exercise
- Not intentionally running blood sugars high
- Eating flexibly most of the time
- Not acting on eating disorder thoughts or feelings
Resources for further support in recovery from an eating disorder as a person with T1D:
- National Eating Disorder Association
- ADA Mental Health Provider Directory
- WeAreDiabetes.org
- Diabulimia Recovery: 3 Patients Share Their Story
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