Eating Disorders with Insulin Manipulation for Weight Loss
People with type 1 diabetes face many challenges. These challenges can include how to fit in physical activity, figuring out how many carbohydrates are in a meal, knowing how much insulin to bolus at a meal, and recognizing symptoms of high and low blood sugars. A challenge that may get overlooked for patients with type 1 diabetes is finding a healthy weight and maintaining that weight. Many providers are understandably concerned and focused on the patient’s A1C value, cholesterol numbers, or symptoms of retinopathy or neuropathy. Providers can forget to ask a patient how he or she feels about their weight and what steps a patient may be taking to lower their weight in a healthy manner. It is extremely important to ask these questions and help patients problem solve in order to prevent the use of insulin manipulation for weight loss.
What is Insulin Manipulation?
Insulin manipulation is a form of purging calories from the body. When a person skips their insulin dose or does not take enough insulin to lower their blood sugar, blood sugar rises and calories are released through the urine. This can lead to weight loss. Without the correct amount of insulin, a person can become dehydrated, thinking they have lost body fat when in actuality, mostly water has been lost. This practice can have negative short and longterm consequences for a person with type 1 diabetes.
What is the Prevalence of Eating Disorders in Type 1 Diabetes?
In Western countries, it has been reported that anorexia affects between 0.1-5.7% of all females and bulimia affects 0.3-7.3% of all females.1 How does this compare to the prevalence of eating disorders in females with type 1 diabetes?The research is limited and varying. However, one of the most recent studies suggests eating disorders are more prevalent in females with type 1 diabetes (10%) than in age matched non-diabetic controls (4%). It is thought that females with type 1 diabetes are more at risk for eating disorders because:2
- Women with diabetes tend to have a higher body mass index.
- There is a cycle of weight loss at disease onset and the subsequent weight gain with treatment.
- Dietary restraint is required for diabetes management.
- The availability of insulin for deliberate insulin manipulation for weight loss.
What Are the Consequences of Insulin Manipulation in Type 1 Diabetes?
The process of insulin manipulation puts patients at risk for severe hyperglycemia, diabetic ketoacidosis, and long-term complications of diabetes.3 In one study of women ages 16-40, the women who manipulated insulin were found to have worse glycemic control, more negative attitudes towards diabetes management, and were more likely to report symptoms of anorexia and bulimia than non-manipulators. In addition, the insulin manipulators were more likely to lie to their physicians regarding their diabetes management.4 Another study reports that women who omit or under dose insulin have significantly higher hemoglobin A1C values when compared to women who do not manipulate insulin. The women in the insulin manipulation group had an average hemoglobin A1C of 11.1 and the non-disordered eating group had an average hemoglobin A1C of 8.7. This same study showed that 86% of women with disordered eating and insulin manipulation developed retinopathy within four years.5
Prevention of Eating Disorders in Patients With Type 1 Diabetes
- Help patients understand the importance of managing their diabetes and the roles healthy eating and exercise play in that management.
- Promote regulated eating by helping patients understand when they are hungry and when they are full.
- Avoid putting foods into categories such as good, bad, fattening, or unsafe.
- Encourage a balance of nutritious foods for meals and snacks plus outline the dangers of dieting.
- Teach patients about healthy body image.
- Encourage patients to talk positively regarding what their bodies do for them.
- Talk about eating and diabetes management in terms of health, pleasure, and satisfaction, not always with regard to weight.
- Encourage regular physical activity for strength, energy, and good health.
- Discuss the ways genetics can determine body shapes.
- Teach patients to recognize a healthy body image verses the unrealistic/unattainable body image represented in the media.
Society puts a lot of pressure on people to be thin. This pressure can be overwhelming for a person with type 1 diabetes. Pressure to be at a lower weight on top of trying to achieve good blood sugar control, correct insulin dosing, healthy cholesterol numbers, and blood pressure can be too much. Insulin manipulation can appear to be the answer for some people. It is extremely important to educate patients on healthy weight control practices and to make patients aware of the harmful, long-term effects of insulin manipulation.
- Makino M, MD, PhD; Tsuboi K, MD, PhD; Dennerstein L, AO MBBS, PhD, DPM, FRANZCP. Prevalence of eating disorders: a comparison of western and non-western countries. Medscape General Medicine. 2004; 6 (3): 49.
- Jones J, Lawson, M, Daneman D, Olmsted M, Rodin G. Eating disorders in
adolescent females with and without type 1 diabetes: cross sectional study. BMJ. 10 June 2000.
- Polonsky WH, Anderson BJ, Lohrer PA, Aponte JE, Jacobson AM, Cole CF.
Insulin omission in women with IDDM. Diabetes Care. 1994 Oct; 17 (10) 1178-85.
- Biggs MM, Basco MR, Patterson G, Raskin P. Insulin withholding for weight control in women with diabetes. Diabetes Care. 1994 Oct; 17 (10) 1186-9.
- Rydall AC, Rodin GM, Olmsted MP, Devenyi RG, Daneman D. Disordered eating behavior and microvascular complications in young women with insulin-dependent diabetes mellitus. N Engl J Med. 1997 Jun; 336 (26) 1849-54.