Type 1 diabetes and eating disorders: How can they be detected and treated?

There is a link between type 1 diabetes and eating disorders despite the importance of a balanced diet in the management of this disease.

Diabetes is a chronic autoimmune condition, caused by the dysfunction of mechanisms regulating blood sugar. Type 1 diabetes (T1D) is also called insulin-dependent, and results from the destruction of pancreas cells responsible for generating insulin. This disease is treated by insulin injections, which lower blood sugar levels.

Patients with type 1 diabetes have a high risk of developing eating disorders.

Eating disorders are complex disorders characterized primarily by abnormal eating habits, an intense fear of gaining weight, and a great concern for body image. The different types of eating disorders are anorexia, bulimia, and binge eating disorder (a disorder characterized by recurrent episodes of eating large quantities of food without using compensatory measures such as vomiting or taking laxatives).

About 9% of the U.S. population, or 28.8 million Americans, will have an eating disorder in their lifetime. The diagnosis is most common in individuals aged between 16 and 40. About 26% of people with eating disorders attempt suicide.

Why are type 1 diabetes and eating disorders related? 

People with diabetes are more likely to develop eating disorders than other people. In T1D, the lack of insulin has a huge influence on weight loss, which can lead to poor adherence to treatment. Some people limit their treatment intake in order to lose weight, risking serious complications such as blindness or amputation. This phenomenon is particularly frequent in teenagers.

The origin of this behavior is often linked to the fact that insulin injections allow the sugar to enter body cells for their energy needs and the excess of sugar is stored as fat. The main risk is that, without insulin, the excess of sugar will remain in the blood and damage small vessels, like those located in the eyes, kidneys and body extremities.

The aim of such unhealthy behavior is to control weight by making oneself vomit, using laxatives or diuretics, following very restrictive diets, having periods of fasting, etc.

The prevalence of anorexia nervosa in patients with T1D is comparable to that in the general population. On the other hand, that of bulimia seems to be higher. This is called “diabulimia”.

What is “diabulimia” ? 

This non-medical term combines two diseases: type 1 diabetes and an eating disorder. It is described in the media as the most dangerous eating disorder in the world because of the disastrous consequences it can have.

According to a study conducted by the association Diabetes Care, those most affected are young patients with T1D, aged 15 to 30, mainly females, perfectionists, with low self-esteem and living in a complex family environment.

Patients with diabulimia take advantage of the effect the insulin has on metabolism, in order to maintain extremely low weight. A person with diabetes can limit their insulin doses in order to stay thin and to prevent insulin from contributing to their weight gain, thus risking to provoke hyperglycaemic coma. This way the patient's refusal of insulin is combined with his or her bulemia.

Complications of diabulimia include the increased risk of kidney damage, blindness or diabetic retinopathy, peripheral arterial disease (diabetic foot), delayed or missed periods, stunted growth, hair loss, skin problems and diabetic ketoacidosis among others. Suicide rate is also high among this population.

Today, diabulimia is not yet recognized as an eating disorder, although it is estimated that 6 to 7% of patients with T1D are affected. This means that there is no appropriate care plan for these patients.

What are the risk factors of developing an eating disorder with type 1 diabetes?  

Certain aspects of diabetes can trigger or contribute to maintaining one of these disorders.

For example, starting a diet to treat one's diabetes can be a trigger, the management of the disease requires quantifying the intake of carbohydrates and controlling one's diet, if the person is psychologically vulnerable, he or she may be predisposed to develop an eating disorder.

It has also been found that most people newly diagnosed with type 1 diabetes gain weight when they start treatment. In addition, insulin is a hormone that can promote the storage of body fat in a sedentary person and, on the contrary, promote the development of muscle mass in a physically active person, which can result in weight gain.

The psychological impact of this chronic condition should also be taken into account.

What are the signs that should alert? 

As there is a risk of death in people with diabetes suffering from eating disorders, it is essential to be able to recognize the signs early.

For example, a patient with T1D who has an unexplained blood sugar imbalance should be tested for an eating disorder.

Also, significant weight loss is the first warning sign that can suggest an eating disorder in a type 1 diabetic. Other signs should require special attention:

• Eating little or eating low-calorie foods,
  
• Secret eating,
  
• Skipping meals,
  
• Using laxatives,
  
• Making oneself vomit,
  
• Excessive physical activity,
  
• Having recurrent infections,
  
• Cancelling medical appointments,
  
• Worrying excessively about one's weight or body image,
  
• Showing signs of depression, moodiness, severe fatigue,
  
• Depriving oneself of insulin doses,
  
• Wearing loose clothes or lots of layers,
  
• Having a higher than normal rate of glycated hemoglobin over a long period of time,
  
  

The management of eating disorders in T1D patients is complicated, it relies on a multidisciplinary approach capable of understanding nutritional, psychological and environmental aspects, but also the issues directly related to T1D and its treatment.

Screening for and diagnosing an eating disorder is difficult because patients often deny or conceal their troubles. However, if an eating disorder is suspected, there is a SCOFF questionnaire, which consists of 5 questions. A positive answer to two or more questions indicates the presence of an eating disorder.