Diabulimia symptoms and warning signs

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Diabulimia is an eating disorder that occurs in people with Type 1 diabetes where they restrict or skip insulin treatments. Diabulimia is not  classified with a separate diagnostic code in the DSM 5 as an eating disorder, so a person’s specific diagnosis will depend on their eating disorder behaviors. Medical professionals categorize it as an eating disorder that occurs alongside diabetes. (1) 

For example, it may be coded as bulimia nervosa (BN) if the person is binging then restricting insulin. It may be diagnosed as a purging disorder if the person is eating normally and restricting insulin. Or, it may be diagnosed as anorexia nervosa (AN)  if the person is severely restricting both food and insulin. Diabulimia can also be diagnosed as Other Specified Feeding and Eating Disorder (OSFED). (2)  It is most commonly seen in young girls but can develop in any gender or age.

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Signs of diabulimia

Because they can be attributed to many types of eating disorders, depending on the behavior exhibited, the signs of diabulimia can be hard to identify. Doctors also may attribute them to diabetes or diabetes-related complications.

Physical signs of diabulimia

Diabulimia can cause physical changes in a person's body. A person with diabulimia may exhibit the following:

Delayed puberty

In girls, delayed puberty may mean no breast development or menstrual period by 15. It may result in no pubic hair or testicular enlargement in boys by 15. Diabetes and eating disorders on their own both can contribute to delayed puberty. For an adolescent with diabulimia, there is an even greater risk. (3) In most cases, once treatment for diabulimia starts, the adolescent will go through puberty without any physical complications. However, delayed puberty can cause stress in teenagers, and they may need emotional support to cope.

Weight loss

A common physical change in a person with diabulimia is weight loss, often a result of food restriction or purging. The role of food is to nourish the body and keep it functioning correctly. Without enough nutrients, a person may experience decreased weight. And losing weight quickly can cause various health concerns such as hair loss, fatigue, and brittle bones. 

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Emotional and behavioral signs of diabulimia

Diabulimia can take a mental and emotional toll on an individual. Emotional and behavioral signs of diabulimia may include: 

Depression

It's common for a person with an eating disorder to experience depression. With diabulimia, the person lives with a chronic condition, diabetes, they may feel they have no control over. And managing life with diabetes can feel overwhelming and stressful at times. Compounded with an eating disorder, a person with diabulimia may experience episodes of depression.

It's important to note that depression is more than feeling sad. It is a medical condition that significantly impacts how people navigate their daily lives. Depression can manifest in different ways, depending on the person, but may include fatigue, disrupted sleep patterns, disinterest in hobbies, social isolation, irritability, and an overwhelming sense of hopelessness. 

Excessive exercising

Some people with diabulimia develop compulsive behaviors. For some individuals, those compulsive behaviors center around managing their food. For others, that compulsive behavior may come out in the form of excessive exercise.

There's an underlying anxiety about gaining weight for many individuals with diabulimia. In addition to restricting insulin and possibly restricting food, people with diabulimia turn to exercise. Working out when done in moderation is a great way to keep the body strong. However, too much exercise, especially without the proper nutrition, can be dangerous. Any person experiencing dizziness, confusion, or intense pain while working out should consult a doctor right away.   

Avoiding doctor's appointments

Many people with diabetes visit their doctors often to ensure their condition is not getting worse or severely interfering with their lives. During these routine visits, a doctor may test blood sugar levels and perform other physical tests to understand the patient's overall health.

These tests can determine if a person with diabulimia is restricting their insulin. While skipping insulin treatments alone does not automatically mean a person has diabulimia, doctors will typically ask their patients questions to assess if they're at risk for an eating disorder. Someone with diabulimia may feel embarrassed or shameful about their condition and avoid routine checkups. They may regularly cancel or lie to family to avoid confronting their diabulimia.

Symptoms of diabulimia

Loved ones and medical professionals cannot observe the symptoms of diabulimia. The individual living with the condition experiences symptoms. Someone who may have diabulimia must communicate their symptoms to a medical professional to thoroughly assess their condition. Symptoms may vary depending on the individual. 

Physical symptoms of diabulimia

Diabulimia can produce a range of physical symptoms. Some common physical symptoms of diabulimia are: 

Ketoacidosis

Ketoacidosis is a common complication among people with Type 1 diabetes and diabulimia. It develops when a person doesn't have enough insulin to convert blood sugar into energy. In the early stages of ketoacidosis, an individual may experience frequent urination and extreme thirst. If left untreated, a person may develop dry mouth, headache, muscle stiffness, or body aches. Ketoacidosis is a life-threatening complication and should be addressed by a medical professional as soon as possible.

Fatigue

Type 1 diabetes means a person's body is not producing insulin. The body uses insulin to regulate blood sugar levels. It breaks down the sugar, also called glucose, and turns it into energy for the body. Since a person with Type 1 diabetes does not produce insulin, they must inject insulin into their body. When someone with diabulimia restricts their insulin, the body cannot convert glucose into energy, which is the body's top source of energy. This can lead to fatigue, making an individual feel mentally and emotionally drained. 

Changes in blood sugar

Insulin plays a vital role in maintaining blood sugar levels. When a person with diabulimia is not giving their body enough insulin to regulate their blood sugar, it can change the amount of glucose in the blood. If blood sugar levels get too high, it can cause hyperglycemia. (4) If left untreated, hyperglycemia can lead to a diabetic coma or complications of the heart, eyes, and kidneys. Doctors can treat high blood sugar with fluid and electrolyte replacements. 

Emotional and behavioral symptoms of diabulimia

Diabulimia can take a toll on a person's emotions and may also cause changes in their behaviors. A few notable emotional and behavioral symptoms of diabulimia include: 

Restrictive eating

People with diabetes regulate their eating habits to maintain their blood sugar levels. From a young age, they may develop restrictive eating behaviors, which can later develop into a disordered pattern of trying to control their weight. (5) When the individual avoids certain foods unrelated to their diabetes management, this may be a symptom of diabulimia. 

Binge eating

Some people with diabulimia may start binge eating. The binge eating may be in response to prior food restrictions or followed by a purging episode, such as self-induced vomiting or laxative use. 

Neglecting diabetes management

Diabetes is a chronic, lifelong condition that, while  manageable,  is not reversible. Type 1 diabetes is generally diagnosed at an early age and requires ongoing management, primarily through careful eating and insulin treatments. In some cases, a person with diabulimia may develop a fear that insulin is the cause of unwanted weight gain and start restricting their insulin intake.

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When to get help for diabulimia

Diabulimia can be life-threatening for a person with Type 1 diabetes. A person with Type 1 diabetes cannot naturally make insulin, which the body needs to break down the sugar in foods to produce energy. When someone with diabulimia restricts their insulin, they increase their chances of severe health concerns, such as liver disease, stroke, or a coma. If you think you or someone you love may have diabulimia, it's essential to reach out for help as soon as possible. 

It can be hard to identify providers who are trained and knowledgeable about disordered eating. Medical providers are not always familiar with the nuances of eating disorders and the multidisciplinary team approach that is often most helpful to treat eating disorders effectively.

Receiving comprehensive treatment may include a team of dietitians, medical professionals, therapists, counselors, and other practitioners well-versed in eating disorders to help patients in their healing journey.

Within Health is here to help all those who need support in treatment of their eating disorders. We provide virtual treatment programs tailored specifically for each patient’s individual needs. Call us now to learn about how you can start treatment for diabulimia at home.

Disclaimer about "overeating": Within Health hesitatingly uses the word "overeating" because it is the term currently associated with this condition in society, however, we believe it inherently overlooks the various psychological aspects of this condition which are often interconnected with internalized diet culture, and a restrictive mindset about food. For the remainder of this piece, we will therefore be putting "overeating" in quotations to recognize that the diagnosis itself pathologizes behavior that is potentially hardwired and adaptive to a restrictive mindset.

Resources

  1. Rydall, A. C., Rodin, G. M., Olmsted, M. P., Devenyi, R. G., & Daneman, D. (1997). Disordered eating behavior and microvascular complications in young women with insulin-dependent diabetes mellitus. New England Journal of Medicine, 336(26), 1849–1854. https://doi.org/10.1056/nejm199706263362601
  2. National Eating Disorders Association. Diabulimia. (2021)
  3. Cedars-Sinai. (n.d.). Delayed Puberty. Cedars-Sinai. Retrieved December 6, 2021, from https://www.cedars-sinai.org/health-library/diseases-and-conditions---pediatrics/d/delayed-puberty.html.
  4. Mayo Foundation for Medical Education and Research. (2020, June 27). Hyperglycemia in diabetes. Mayo Clinic. Retrieved December 6, 2021, from https://www.mayoclinic.org/diseases-conditions/hyperglycemia/symptoms-causes/syc-20373631
  5. Kinik, M. F., Volkan Gonullu, F., Vatansever, Z., & Karakaya, I. (2017). Diabulimia, a type I diabetes mellitus-specific eating disorder. Türk Pediatri Arşivi, 52(1), 46–49. https://doi.org/10.5152/turkpediatriars.2017.2366

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