Disordered Eating in Type 1 Diabetes
Written by Helen d’Emden AdvAPD CDE
Disordered eating is common in young people with type 1 diabetes and can persist into adulthood. It is estimated to occur in 30-40% of females and 10% of males. Furthermore, clinical eating disorders are also twice as common in girls with type 1 diabetes than their peers. With binge eating disorders, other specified feeding and eating disorders and bulimia nervosa the most common types. Anorexia Nervosa is also seen but prevalence rates are similar to the general population.
Causes of disordered eating in people with type 1 diabetes
The diabetes-specific reasons for the higher rates of disordered eating and eating disorders include:
- Weight loss prior to the diagnosis due to the lack of insulin followed by weight restoration when insulin is commenced which can contribute to body dissatisfaction.
- Diabetes management has an intense focus on carbohydrate counting and blood glucose levels.
- There is a focus on weight as it is routinely monitored at clinic visits to assess insulin requirements and growth
- Episodes of recurrent hypoglycaemia can trigger binge-eating episodes and weight gain.
- The ability to restrict or omit insulin, a unique purging behaviour to achieve weight loss for those with type 1 diabetes, without the need for significant food restriction
- The increased task and associated burden associated with managing such a complex chronic health condition along with the effect on self-esteem.
- The obvious need for increased autonomy with age related to diabetes self-management, and how the parents and family manage this.
Consequences of disordered eating in type 1 diabetes
Disordered eating and eating disorders cause serious health consequences for those with type 1 diabetes. There are increased rates nephropathy, neuropathy and retinopathy. There is an increased risk of diabetes ketoacidosis especially when insulin omission is present. Mental health impairment is seen with higher rates of anxiety, depression and diabetes distress. Quality of life can be impacted with fatigue and sleep disturbances, excessive hunger and thirst, dehydration, muscle atrophy, menstrual and hormone disturbances and digestive problems. Other potential concerns are electrolyte abnormalities, postural hypotension, bradycardia and tachycardia. Those who have comorbid anorexia nervosa and T1DM have 5-10 times higher mortality rates than those who have anorexia nervosa or type 1 diabetes alone.
It is very important that health providers looking after young people with T1DM are aware of the signs and symptoms of disordered eating. There are many potential indicators which include behavioural and psychosocial signs, diabetes management signs and medical indicators. Disordered eating needs to be identified and addressed early so thoughts and behaviours do not become entrenched.
Assessing disordered eating
Until now clinical pathways and practical guidelines to assess and address disordered eating and eating disorders have been lacking. This has posed considerable challenges, even to experienced diabetes teams.
The Queensland Diabetes State-wide Clinical Network sought to develop a consensus clinical guideline to inform health professionals who work with those with type 1 diabetes. A working group of diabetes and eating disorder professionals from QLD, NSW and Victoria was established with clinical and research experience. Consumer and peer reviews were sought. They address the definition of disordered eating and eating disorders, along with strategies for prevention, the aetiology, prevalence and consequences. They also include information on a stepped care model of assessment, and interventions involving all members of the multidisciplinary team. Importantly, they will inform when to escalate care and the indicators for hospital admission. Clinical guidelines can be found on the Queensland health website: Disordered Eating (DE) and Eating Disorders (ED) in Adults with Type 1 Diabetes (T1D) (age 16 years and over)
Enrol in the disordered eating and eating disorders in type 1 diabetes pre recorded webinar on our website here
For people with type 1 diabetes, insulin is a lifesaving medication. Missing insulin however, even if only occasionally, can be detrimental to health. If restricting insulin becomes a regular occurrence, this behaviour can develop into an eating disorder called Diabulimia.
It’s estimated that up to 40% of people with type 1 diabetes misuse insulin for weight control at some point, yet taking insulin needn’t be a barrier to maintaining a healthy weight.
There are variety of reasons that insulin might affect weight and diabetes teams can help to identify these issues. It may also be important to remind people that weight gain, particularly following diagnosis or for growing children, can be a normal part of staying healthy.
Modifiable conditions where insulin might make it difficult to manage weight:
- Frequently needing to treat or avoid hypos
- Eating to match insulin, rather than to satisfy appetite
- Eating to reduce hypos during exercise
Click here to listen to our Diabulimia podcast. Kate Alison, accredited practicing dietitian and Dr Lisa Robins, clinical physiologist discuss diabulimia – the intentional misuse of insulin for people living with type 1 diabetes for weight control.
If you or anyone you know needs help with an eating disorder:
- Butterfly Foundation on 1800 33 4673
- Lifeline on 13 11 14
- Kids Helpline on 1800 551 800
- Beyond Blue on 1300 22 46 36
- Headspace on 1800 650 890