TestingWhat turns difficulties with food into an eating disorder? Put simply, an eating disorder is diagnosed if your attitude towards food causes you to change your eating habits and behaviours in a way that may cause damage to your health. The most common eating disorders are:

Anorexia Nervosa: when someone tries to keep their weight as low as possible, for example by starving themselves or exercising excessively.

Bulimia Nervosa: when someone binge-eats and then tries to control their weight by deliberately being sick or using laxatives (medication to help empty the bowels), diuretics and enemas.

Eating Disorder Not Otherwise Specified (EDNOS): an eating disorder that does not meet the criteria for any specific eating disorder. This includes binge eating disorder, when someone feels compelled to overeat but doesn’t use any compensatory behaviours (such as self-induced vomiting, laxatives, diuretics or enemas).

One type of eating disorder not otherwise specified that is specific to people with diabetes that use insulin is the reduction or omission of insulin. This behaviour is often referred to as ‘diabulimia’ in the media, although most health professionals avoid this term because it is confusing on many fronts. For instance, bulimia involves making yourself sick, which many individuals with diabetes who manipulate insulin do not do. EDNOS-DMT1 (Diabetes Mellitus Type 1) is a preferable term, although the condition is not clinically recognized yet. With insulin omission, whether by decreasing, delaying, or completely omitting prescribed insulin doses, a person with diabetes can induce hyperglycaemia and rapidly lose calories in the urine in the form of glucose.

Insulin manipulation can be done in quite a secretive way, so it often goes undetected by healthcare professionals. Unfortunately, it can also easily be misunderstood and the patient labelled ‘non-compliant’ with treatment. However, individuals who are manipulating their insulin are struggling with an eating disorder.

Signs to Look Out for That May Suggest Insulin Omission

  • Recurrent episodes of Diabetic Ketoacidosis (DKA)/ Hyperglycaemia.
  • High HbA1c.
  • Frequent hospitalizations for poor blood sugar control.
  • Delay in puberty or sexual maturation, or irregular periods.
  • Frequent trips to the toilet.
  • Frequent episodes of thrush/urine infections.
  • Nausea and stomach cramps.
  • Loss of appetite/eating more and losing weight.
  • Drinking an abnormal amount of fluids.
  • Delayed healing from infections/ bruises.
  • Easy bruising.
  • Dehydration and dry skin.
  • Dental problems.
  • Blurred vision.
  • Severe fluctuations in weight.
  • Fractures/bone weakness.
  • Anaemia and other deficiencies.
  • Early onset of diabetic complications, particularly neuropathy, retinopathy, gastroperisis, and nephropathy.
  • Anxiety/distress over being weighed at appointments.
  • Fear of hypoglycaemia.
  • Fear of injecting/extreme distress at injecting.
  • Injecting in private/out of view.
  • Avoidance of diabetes-related health appointments.
  • Lack of BS testing/reluctance to test.

Causes of Eating Disorders

Causes of eating disorders are complex, and there is rarely one specific cause. Rather, as with other emotional difficulties there are biopsychosocial reasons for their development and continuation. The reasons that disordered eating may develop in the general population (i.e. non diabetes-specific reasons) are:


  • Having a family history of eating disorders, depression or substance misuse.
  • Being female (although men are also increasingly vulnerable and do also develop eating disorders).
  • Being Overweight.
  • Experiencing early puberty compared to peers.


  • Being overly concerned with being slim, particularly if combined with pressure to be slim from society or for a job (which can happen, for example to ballet dancers, models, or athletes).
  • Certain characteristics, for example having an obsessive personality, an anxiety disorder or low self-esteem, or being a perfectionist.
  • Dietary restraint and dieting.


  • Being criticized for one’s eating habits, body shape, or weight.
  • Particular experiences, such as sexual or emotional abuse, or the death of someone special.
  • Difficult relationships with family members or friends.
  • Stressful situations, for example problems at work, school, or university.
  • Disturbed family functioning.
  • Disturbed parental eating attitudes.
  • Peer and cultural influences.

Eating disorders are often blamed on the social pressure to be thin. However, although this can be a contributing factor for some individuals, the causes are usually more complex. Many people do feel a pressure to be slim but do not go on to develop an eating disorder.

If you are struggling with an eating disorder it is not your fault. You are likely to have difficulty in managing and regulating your emotions, and a distorted view of your own body image. You are concerned about your body weight and shape and are likely to believe that you are overweight when you are actually at a normal or low weight. You probably fear gaining weight or becoming fat, and have a concerned attitude towards food, calories, and eating. Thoughts about food, weight, and shape are likely to be on your mind much of the time, and your success in controlling your eating behaviour and weight can become a main way you feel good about yourself.

Considerable evidence has also accumulated to suggest that living with type 1 diabetes in itself is a risk factor for disturbed eating behaviour and eating disorders (Nielsen, 2002). Eating disorders have been found to be twice as common in teenage girls with type 1 diabetes as in their peers without diabetes (Colton, 2009). It is also argued that the diabetes treatment goals can ‘teach’ or intensify some of the vulnerability to an eating disorders mindset (Goebel-Fabbri, 2009).

Diabetes management increases the focus on controlled food intake, and can be experienced as restrictive. This means you are following an eating plan which is not completely dependent on responding to your own internal cues for hunger and fullness. This results in these cues becoming less reliable. If you under eat, you are likely to feel deprived, which can trigger overeating and binge eating episodes. Knowing that bingeing is not good for your health or weight, you may then intensify your efforts to control your food intake and weight, getting trapped in a cycle of dieting, further binge eating, and weight control behaviour.

Not only this, but at puberty, when weight and shape concerns intensify, diabetes can become more difficult to manage due to hormonal changes and resulting insulin resistance. Diabetes then may constitute a pathway of risk for the development of disturbed eating behaviour.

Insulin Manipulation or Omission

Insulin manipulation is the most common method of purging in girls with type 1 diabetes and becomes progressively more common through the teen years. This behaviour is reported by 2% of pre-teen girls, 11–15% of girls in the mid-teen years and 30–39% of those in the late teenage and early adult years (Colton, 2009).

The reason most frequently cited by women with type 1 diabetes for deliberate insulin omission is weight control. However, other motivating factors may include:

  • Fear of hypoglycaemia.
  • Denial of having diabetes.
  • Embarrassment about blood glucose testing or insulin administration in front of others.
  • Desire to have a break from diabetes management.
  • Fear of needles.
  • Secondary weight gain.

Overcoming Insulin Omission and Other Eating Disorders

I have a 10-step programme for breaking free of these patterns of behaviour.

  1. Get ready to change.
  2. Keep a diary.
  3. Develop an insulin/food plan.
  4. Reduce binge eating.
  5. Reduce vomiting/laxative use.
  6. Examine your thinking.
  7. Problem-solve.
  8. Expect challenges.
  9. Increase self-esteem.
  10. Speak up.

I’d love to support you in working through the 10 steps of this programme. If you are currently struggling with insulin omission (or any other emotional issue related to your diabetes), remember you can take advantage of a totally free “Diabetes Clarity Session”  — a 30-minute telephone call with me or a member of my team to get clear on a plan for getting better. I really want to do all I can to help you achieve your best health and wellbeing this year.

You may use this article on your website, or for your own e-zine; however, there's one thing you MUST include: Dr. Jen Nash is a Clinical Psychologist chartered with the British Psychological Society. Dr. Jen helps her clients find solutions with simple and highly-effective psychological strategies to gain freedom from the frustration and stress of living with diabetes. To sign up for her free Diabetes Diary, visit www.PositiveDiabetes.com.