Eating disorders are incredibly complex, in part because they often occur with other physical and mental conditions. One such condition is diabetes, a chronic disease that requires medical intervention and lifelong maintenance. This maintenance often includes close attention to diet and exercise, which are areas of particular concern for those susceptible to developing, experiencing, or recovering from eating disorders.
Read on to learn about how diabetes intersects with eating disorders and the potential health consequences for those experiencing both conditions.
The Prevalence of Eating Disorders in People with Diabetes
Individuals with diabetes have a heightened risk of developing an eating disorder. For example, several studies have found that adolescents with type 1 diabetes are more likely to experience disordered eating behaviors and eating disorders than their peers without diabetes (Jones et al., 2000; Young et al., 2013). In addition, it is estimated that between 12% to 40% of people with type 2 diabetes have an eating disorder (García-Mayor & García-Soidán, 2017).
This heightened eating disorder risk for those with diabetes could be attributed to a myriad of factors, including a close focus on food; stress from managing a serious, chronic, and often stigmatized illness; food being labeled as “good” and ”bad” in the context of diabetes; and weight changes related to insulin use.
Type 1 Diabetes and Eating Disorders
Type 1 diabetes is a chronic condition where the pancreas makes little or no insulin, the hormone that controls blood sugar (glucose) levels in the body. Without enough insulin, glucose builds up in the bloodstream and cannot be used for energy. Type 1 diabetes often appears during childhood or adolescence, an age when the risk for developing an eating disorder is also heightened.
Type 1 diabetes management requires monitoring blood sugar and insulin levels, which are impacted by diet and activity. Shots or pumps can provide the insulin necessary to manage type 1 diabetes, but insulin can also be misused to manipulate weight or body shape. The media-coined term for this type of insulin mismanagement is “diabulimia.” Insulin mismanagement is a type of purging that can cause hyperglycemia, which can result in a condition called ketoacidosis (diabetic coma).
In addition to insulin misuse, those with type 1 diabetes can also engage in other disordered eating behaviors. Known as type 1 diabetes with disordered eating (T1DE), this condition can include behaviors such as food restriction, self-induced vomiting, excessive exercise, constantly discussing their desire to change their weight, size, or shape, and more.
Type 2 Diabetes and Eating Disorders
While those with type 1 and type 2 diabetes both have high levels of blood glucose, type 1 is an autoimmune condition where the body attacks the pancreas and prevents it from producing insulin. Type 2 is categorized as insulin resistance. According to the Mayo Clinic, type 2 diabetes is “an impairment in the way the body regulates and uses sugar (glucose) as a fuel.” Type 2 diabetes is more common in older adults but can also develop during childhood and adolescence.
Some studies suggest that binge eating disorder (BED) and bulimia nervosa may increase the risk of developing this type of diabetes. A 2018 systematic review estimated that binge eating disorder affects 1.2% to 8% of people with type 2 diabetes.
Night eating syndrome (NES), which falls under the OSFED diagnosis, or Other Specified Feeding or Eating Disorders (Canadian Diabetes Association), is also common in adults with type 2 diabetes (Abbot et al. 2018). Night eating syndrome involves recurrent binge eating episodes that occur at night and can result in poor glycemic control and further diabetic complications. Signs of NES include:
- Waking up at night to eat
- Eating more than 25% of daily food intake at night
- Decreased appetite during the day
- Depression and anxiety
Eating Disorder Warning Signs
Warning signs that someone with diabetes (type 1 or 2) may be struggling with an eating disorder include:
- Elevated A1c levels
- Drastic fluctuations in blood glucose levels
- Increasing neglect of diabetes management
- Avoiding diabetes-related appointments
- Extreme increase or decrease in food consumed
- Anxiety about body image
- Avoiding eating with loved ones or in public
- Excessive or rigid exercise
- Preoccupation with food, weight, or calories
- Restricting food or specific food groups
Health Risks of Co-Occurring Diabetes and Eating Disorders
Co-occurring diabetes and eating disorders can be dangerous to physical health.
People living with type 1 diabetes and an eating disorder can experience even more health risks than those with diabetes or disordered eating alone. Insulin misuse, for example, can cause prolonged elevated blood sugar, which can result in irreversible and severe complications, even death. Therefore, early detection and treatment are essential.
Potential consequences of the co-occurrence of diabetes and eating disorders include:
- Stabbing/burning/tingling pain, weakness, or numbness in the hands, feet, legs, and/or arms
- Gastroparesis – slowed stomach emptying from damaged nerves
- Chronic diarrhea or constipation
- Macular edema – swelling of the eyeball from excess fluid
- Heart disease, kidney disease, or liver disease
One aspect of type 2 diabetes management is maintaining a particular diet. Doctors might suggest eating more high-fiber foods, fewer refined grains and sweets, and different portion sizes. Such recommendations may inadvertently rev up eating disorder thoughts and behaviors that interfere with diabetes management.
In a recent study, participants with the dual diagnosis of type 2 diabetes and binge eating disorder confirmed this, sharing how their binge eating episodes negatively affected glycemic management.
Examples of potential complications from mismanaging type 2 diabetes include:
- Kidney damage
- Heart disease
- Neuropathy (nerve damage)
Recovery is Possible
While neither condition causes the other, diabetes and eating disorders are linked in significant ways. It is crucial for healthcare providers, loved ones of those with diabetes, and those with diabetes themselves to be aware of the heightened eating disorder risk. Keeping an eye out for signs of an eating disorder and reaching out for help as soon as possible is essential.
A multidisciplinary care team can help patients regulate eating to support both eating disorder recovery and diabetes management, challenge disordered eating and thinking, and develop coping methods for the stress that comes with diabetes management. Those who experience diabetes and eating disorders may have a more complex road to healing, but eating disorder recovery is nonetheless possible with proper individualized care.