The pressure to stay slim is everywhere, but if an eating disorder develops in someone with type 1 diabetes, the consequences can be dire.
Staying trim sounds like a great idea. But only achieve that goal the safe way. Skipping insulin injections to keep your weight down—a disorder known as diabulimia—can be very dangerous. Here's why, and what you can do to avoid this problem.
What are the risks?
If insulin is withheld, sugar stays in the bloodstream and leaves through the urinary tract, so no weight is gained even after eating a big meal. A dieter's dream, right?
But high blood sugar can ravage blood vessel walls, nerves, kidneys and retinas. What's more, the lack of insulin essentially starves the body of fuel, creating an urge to consume large amounts of calorie-rich food—in what's called a binge. If the cycle continues, blood sugar can reach extreme highs, causing diabetic ketoacidosis (an unsafe level of toxic acids, or ketones, in the blood), coma and even death.
Researchers at the Harvard-affiliated Joslin Diabetes Center in Boston found that women with type 1 diabetes who reported taking less insulin than prescribed were three times more likely to die and had higher rates of disease complications than those who didn't skip insulin shots. The more shots skipped, the higher the risk. Women in the study who eventually died or had serious complications had reported omitting insulin more frequently than women who had no such ill effects.
How widespread is the problem?
Women with type 1 diabetes are more than twice as likely to develop an eating disorder than women of the same age without diabetes, based on the Joslin study. And, at some point in their life, as many as one in three diabetic women will skip insulin injections to lose weight. Experts believe the causes of diabulimia are similar to those of eating disorders in general.
"About 50% of the risk is inherited," says Sharon Alger-Mayer, MD, medical director of the Northeast Comprehensive Care Center for Eating Disorders and associate professor of medicine at Albany Medical College in New York. "Young women who develop eating disorders often have a parent who is preoccupied with weight and body image or a family history of anxiety, depression or substance abuse. But genetics just loads the gun; environment pulls the trigger.
"Women engaged in 'thin activities' like gymnastics, ballet or modeling are strong candidates for eating disorders," she adds. Additionally, a recent review of studies on diabulimia concludes that a chaotic, perfectionist or strongly patriarchal family life also heightens the risk.
Others, like William Polonsky, PhD, director of the Behavioral Diabetes Institute in San Diego, believe that a sense of powerlessness may underlie a diabetes patient's negative behaviors. Well-meaning friends, family or health professionals watch over a diabulimic's every dietary move, for example. That creates a dangerous dynamic in which they play the role of "diabetes police" and the patient becomes the "criminal."
What can be done?
"Parents are the first obstacle I face," says Grace Shih, RD, at Stanford University School of Medicine's Lucile Packard Children's Hospital. "They say to me, 'She's a teenager. Of course she wants to lose weight.' " That perspective, in a nutshell, is the initial hurdle, according to Shih. "An eating disorder is a mental illness," she insists, "not a lifestyle choice."
Instead of pleading with someone to take her insulin, Shih recommends assembling a multidisciplinary team of health providers to address the biological, psychological and social issues involved. The team might include an endocrinologist, a mental-health professional and a dietitian. With the right kind of help, those with diabulimia can learn to see insulin omission as a problem instead of a solution.