Diabetes and Eating Disorders

Living with diabetes can be challenging, but when combined with an eating disorder like anorexia, bulimia, binge eating, or insulin omission (diabulimia), it can get more complex. 

Let’s take a closer look at these eating disorders to learn more about them and find ways to deal with their impact on quality of life and diabetes management. 

11 April 2022
Diabetes and Eating Disorders

Disordered eating vs eating disorder

When someone shows irregular eating habits, such as rigid rituals, anxiety over food, binge eating, vomiting, or an obsession with food and weight, it’s considered disordered eating.1 When these eating habits interfere with the ability to focus or go about one's day, and negatively impact their physical and psychological well-being, disordered eating becomes an eating disorder.

People with diabetes are more likely to struggle with food anxiety, chronic weight changes, or preoccupation with weight and body image — especially women. Focusing too much on diabetes medicine, exercise, and diet can make it harder to manage diabetes, which may increase the risk of developing an eating disorder.1

Recent studies suggest that both type 1 and type 2 diabetes may increase the risk of developing restrictive eating disorders.1  Factors such as irregular meal timing, depressive symptoms, and unhealthy eating habits can contribute to risk. It's important to know the symptoms of eating disorders to help people with diabetes and their healthcare team spot any potential problems early on.

Common eating disorders

Bulimia Nervosa (bulimia)

Bulimia Nervosa (bulimia) is a serious eating disorder that involves binge eating large amounts of food with a loss of control over the eating and then purging, trying to get rid of the extra calories in an unhealthy way.1 This can include vomiting, the use of laxatives, excessive exercise, and other methods.

Anorexia Nervosa (anorexia)

Anorexia Nervosa (anorexia) is an eating disorder characterized by an abnormally low body weight, extreme food restriction, an intense fear of gaining weight, and a distorted perception of weight.1 People with anorexia place a high value on controlling their weight and shape, using extreme weight loss efforts such as self-induced vomiting and laxative abuse that tend to significantly interfere with their lives.2

Binge-eating Disorder

Binge-eating Disorder is a serious eating disorder in which people frequently consume unusually large amounts of food and feel unable to stop eating.1

Other Specified Feeding or Eating Disorder (OSFED)

Other Specified Feeding or Eating Disorder (OSFED) refers to the signs and symptoms of eating disorders that are clinically significant but do not meet the full diagnostic criteria for anorexia, bulimia, or binge-eating disorder.3 OSFED cases include those who have fewer symptoms (e.g., subthreshold BN/BED) or are missing certain symptoms. OSFED makes up the majority of eating disorder diagnoses.

Eating disorder symptoms and warning signs

Now that you know the different types of the more common eating disorders, it’s important to understand the various symptoms and warning signs.

Mental and behavioral symptoms

There are certain mental and behavioral symptoms of eating disorders, including a noticeable change in how people view and approach food, weight, and self-image.1 A strong fear of gaining weight, the need to feel in charge of life, and the habit of looking in the mirror all the time to find flaws can all be signs of an eating disorder.2

When it comes to body image and food, it's common to experience mood swings, which can show up as irritability, depression, or apathy.

Some other common eating disorder symptoms are:1

  • Avoiding eating with others;
  • Strict dieting or overeating
  • Food rituals — cutting food into tiny pieces when unnecessary or excessive chewing
  • Hoarding or hiding food
  • Eating in secret
  • Intense fear of gaining weight
  • Feeling out of control when eating
  • Exercising an unhealthy amount
  • Preventing foods from touching each other or mixing
Physical Symptoms

In addition to the psychological and behavioral signs of eating disorders, some people may also exhibit physical symptoms.4

  • Weight loss or gain
  • Poor sleep
  • Absent or irregular menstruation
  • Dizziness
  • Feeling cold
  • Bloating or constipation
  • Growth stop 
  • Dry skin

Another eating disorder that affects individuals with diabetes is insulin omission, also known as diabulimia.

Diabulimia (insulin omission)

Diabulimia, also known as insulin omission, is one of the most commonly reported eating disorders among people with diabetes– it is a serious condition where people with diabetes skip or lower their insulin doses to not gain any additional weight.1,5 Beyond weight loss, some use this harmful practice for self-harm, to avoid the discomfort of injections, out of fear of low blood sugar, or due to feeling overwhelmed by their diabetes therapy. It's especially common in people with type 1 diabetes, but also affects those with type 2 diabetes on insulin therapy.

Not taking insulin or reducing the dosage causes blood glucose levels to increase.1 Then, the body breaks down fat more quickly and discharges excess glucose from the body through the urine leading to a rapid loss in calories.

Insulin is necessary for people with type 1 diabetes to survive, and skipping doses can cause diabetic ketoacidosis (DKA), a potentially life-threatening condition.6,7 Hyperglycemia will also increase the risk of long-term complications, including retinopathy, nephropathy, and vascular disorders.

How does diabulimia develop?

Diabulimia may develop from a mix of social, mental health, family, media, and physical factors.8 Some of the challenges that come with diabetes management may play a part, such as: 8–11

  • Focusing on weight
  • Constantly counting calories or carbohydrates in meals
  • Difficulty keeping weight at a healthy level
  • Needing to read food labels carefully
  • Losing weight before type 1 diabetes and regaining it after treatment starts
  • Poor relationships with a healthcare professional or team
  • Eating to treat hypoglycemia, which may lead to guilt or weight gain
  • Feeling shame over the way of managing diabetes

Diabulimia may start with a constant focus on managing diabetes and problems with body image, a sense of loss of control, a desire to lose weight or diabetes burnout.8

It is common for people who have recently been diagnosed with type 1 diabetes to lose weight before the diagnosis. Starting insulin therapy may result in regaining the lost weight. This can be difficult to deal with, leading some people to skip insulin doses.

No matter how it begins, it’s often hard to recognize the symptoms of and find successful treatments for diabulimia.

Diabulimia warning signs

There could be emotional, behavioral, and physical signs and symptoms of diabulimia. Many people with diabulimia often keep their condition a secret and may not seek treatment,10 but may show signs of hyperglycemia such as: 8,10

  • Regular attacks of nausea or vomiting
  • Weight loss
  • Dry skin and hair
  • Blurry vision
  • A HbA1c of 9.0% or higher
  • Frequent urination
  • Excessive thirst
  • Irregular or lack of menstrual periods
  • Fatigue
  • Episodes of DKA
Emotional and behavioral warning signs of diabulimia

The physical symptoms of diabulimia are often accompanied by emotional and behavioral warning signs such as: 12

  • Prescriptions that don’t get filled
  • Neglecting diabetes management
  • Fearing low blood sugars
  • Strict food rules
  • Anxiety or depression
  • Being secretive about diabetes management
  • Avoiding eating in public or with others
  • Worrying that insulin will “make me fat”
  • Restricting foods to reduce insulin doses
  • Withdrawing from loved ones
  • Preoccupation with exercise, weight, food, or calories
  • Excessive exercising
  • Avoiding doctors appointments
  • Anxiety about how their body looks

It's important to seek professional help if you suspect that you or someone you know may be experiencing diabulimia or any other eating disorder.

Potential consequences of diabulimia

Diabulimia, or insulin omission, is an extremely dangerous disorder.1 Having both type 1 diabetes and an eating disorder like diabulimia can cause high HbA1c levels and a higher risk of both short-term and long-term complications, which can lead to more hospital visits and longer stays.10,13,14

Short-term insulin omission will increase blood glucose levels, causing:8

  • Fatigue
  • Dehydration
  • Risk of diabetic ketoacidosis (DKA)

Long-term high levels of blood glucose can cause: 8

  • Damage to blood vessels, leading to eye problems (retinopathy)
  • Nerve damage leading to chronic constipation or diarrhea
  • Burning, tingling, or weakness in arms, legs, feet, or hands (known as peripheral neuropathy)
  • Poor metabolic control
  • Damage to kidneys, liver, or heart

Diabulimia may increase the risk of long-term complications from diabetes and can be deadly. 1

Diabetic ketoacidosis (DKA)

Diabetic ketoacidosis can lead to coma or death.13 Look out for DKA symptoms, such as:

  • Thirst
  • Hunger
  • Frequent urination
  • Nausea and vomiting
  • Shortness of breath
  • Fruity-scented breath
  • Feeling tired or fatigued

DKA symptoms might require emergency medical attention.7 If you recognize any of these symptoms, consult with a healthcare professional as soon as possible.

Diabulimia and eating disorder treatments

The chance of recovery from an eating disorder and diabulimia increases the earlier it is detected.1 If you find yourself or a loved one fixating on food or diabetes therapy, obsessing over body image, or developing unhealthy habits, seek help from friends and family, medical professionals, and therapists.

Since diabulimia is not a recognized mental disorder, it often gets overlooked or misunderstood.14,15 Treatment requires a full team of specialists to help the patient recover. This may include an endocrinologist, a mental health professional specializing in eating disorders, and a dietician.

Ask for help

Managing diabetes isn’t easy, but having to deal with an eating disorder or diabulimia makes things harder. You may be having a difficult time with how you feel about your body and are experiencing shame or guilt for keeping your potential eating disorder from the people you care about and your medical team.

It’s important to remember that when you’re fighting a serious problem, you’re never alone. While it might be difficult, asking for help is the first step to recovery. Talk to someone you trust and bring it up with your physician. Breaking the cycle of an eating disorder or diabulimia can be challenging, but recovery is possible with help and support.

  1. Dziewa M, Bańka B, Herbet M, Piątkowska-Chmiel I. Eating Disorders and Diabetes: Facing the Dual Challenge. Nutrients. 2023;15(18). doi:10.3390/nu15183955
  2. Fairburn CG, Harrison PJ. Eating disorders. The Lancet. 2003;361(9355):407-416. doi:10.1016/S0140-6736(03)12378-1
  3. Withnell SJ, Kinnear A, Masson P, Bodell LP. How Different Are Threshold and Other Specified Feeding and Eating Disorders? Comparing Severity and Treatment Outcome. Front Psychol. 2022;13:784512. doi:10.3389/fpsyg.2022.784512
  4. Treasure J, Duarte TA, Schmidt U. Eating disorders. The Lancet. 2020;395(10227):899-911. doi:10.1016/S0140-6736(20)30059-3
  5. American Diabetes Association Professional Practice Committee. 15. Management of Diabetes in Pregnancy: Standards of Care in Diabetes—2024. Diabetes Care. 2023;47(Supplement_1):S282-S294. doi:10.2337/dc24-S015
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  7. Calimag APP, Chlebek S, Lerma EV, Chaiban JT. Diabetic ketoacidosis. Dis Mon. 2023;69(3):101418. doi:10.1016/j.disamonth.2022.101418
  8. Hall R, Keeble L, Sünram-Lea SI, To M. A review of risk factors associated with insulin omission for weight loss in type 1 diabetes. Clin Child Psychol Psychiatry. 2021;26(3):606-616. doi:10.1177/13591045211026142
  9. Goddard G, Oxlad M. Insulin restriction or omission in Type 1 Diabetes Mellitus: a meta-synthesis of individuals’ experiences of diabulimia. Health Psychol Rev. 2023;17(2):227-246. doi:10.1080/17437199.2021.2025133
  10. Winston AP. Eating Disorders and Diabetes. Curr Diab Rep. 2020;20(8):32. doi:10.1007/s11892-020-01320-0
  11. Diabetes UK. Diabulimia and diabetes. Diabetes UK. Accessed November 7, 2023. https://www.diabetes.org.uk/guide-to-diabetes/life-with-diabetes/diabulimia
  12. Diabulimia: What It Is, Symptoms, Risk Factors & Treatment. Cleveland Clinic. Accessed November 30, 2023. https://my.clevelandclinic.org/health/diseases/22658-diabulimia
  13. Calimag APP, Chlebek S, Lerma EV, Chaiban JT. Diabetic ketoacidosis. Dis Mon. 2023;69(3):101418. doi:10.1016/j.disamonth.2022.101418
  14. Coleman SE, Caswell N. Diabetes and eating disorders: an exploration of ‘Diabulimia.’ BMC Psychol. 2020;8(1):101. doi:10.1186/s40359-020-00468-4
  15. National Institute for Health and Care Excellence. Recommendations | Eating disorders: recognition and treatment | Guidance | NICE. NICE. Published May 23, 2017. Accessed February 9, 2024. https://www.nice.org.uk/guidance/ng69/chapter/Recommendations#physical-and-mental-health-comorbidities