Diabulimia: health versus body image in type 1 diabetes

Lowering insulin doses can have dangerous effects on the body. Jill A Brown

Many people around the world take insulin injections to manage their type 1 diabetes. Although it’s essential for their health, some dangerously manipulate their treatment to lose weight.

Insulin is a hormone made by the beta-cells of the pancreas. Its key function is to facilitate the uptake of glucose and fat out of the bloodstream after eating. Insulin also suppresses pathways that trigger the release of glucose and fat back into the blood when we’re not eating.

In type 1 diabetes, the ability to make insulin is destroyed by the immune system. In order to survive, people with type 1 diabetes must inject themselves with insulin every day. Without insulin treatment, their glucose fails to enter cells normally, instead remaining stuck in the blood.

High blood glucose levels have a number of adverse effects on human health. The most obvious comes as glucose spills over into the urine, making you pee more, drying you out and making you drink more, as a result. This is why the Greeks named this condition “diabetes mellitus”, meaning “the siphon of (sweet-tasting) honey”.

Losing large amounts of glucose (calories) into the urine has another important effect too. Without insulin treatment, people with type 1 diabetes quickly and dramatically lose weight. In fact, before insulin became available, people with type 1 diabetes had the same emaciated look as those with anorexia.

The discovery of insulin in the 1920s changed this dramatically. Suddenly, gaunt adolescents with type 1 diabetes began to put on weight and their survival improved spectacularly.

Before insulin, type 1 diabetes caused severe malnourishment. Wikimedia Commons

But for people with type 1 diabetes to really prosper, the delivery of insulin must be carefully adjusted, just as is done by a healthy pancreas. The idea is to deliver the right dose of insulin at the right speed and time for each individual.

This is no easy task – too little insulin and the blood glucose levels rise; too much insulin and they fall.

While this may sound complicated, insulin is taken routinely and effectively by thousands of Australians with type 1 diabetes every day. And not only do they prosper, but most adults with type 1 diabetes have superior health outcomes compared to the general population.

The insidious problem of diabulimia

Many people with type 1 diabetes recognise a relationship between the amount of insulin they take and their weight, and often struggle to balance control of their weight against the demands of their treatment.

But while dietary restrictions and physical activity are recommended, it is now clear that up to a third of people with type 1 diabetes deliberately miss or reduce their insulin dose in order to lose weight.

This practice is sometimes known as diabulimia, as it shares some characteristics with disturbed eating behaviours in which self-evaluation is unduly influenced by body weight or shape, often at the expense of personal health and safety. It is more common in adolescents and women and may sometimes coexist with other eating problems.

Missing doses usually starts off as an occasional thing, sometimes to avoid hypoglycaemia or the requirement to snack to prevent it. Sometimes it is accidental. But as weight is lost, it reinforces the behaviour. Insidiously, skipping insulin doses becomes an easy way to independently regain weight control without the constraint of diet or exercise.

However, uncontrolled glucose levels, even in the short term, carry a number of serious risks including dehydration, muscle wasting, infections, ketoacidosis and even death.

There are many safer ways to lose weight if you have type 1 diabetes. Regular physical activity not only burns excess calories but also makes the body more sensitive to insulin. Similarly, simple dietary changes can help limit excess calorie consumption, reducing the need for insulin.

It’s important to remember that if you have type 1 diabetes, the only safe way to take less insulin is to need less insulin.

Refining a blunt tool

New treatments are trying to make diabetes control with insulin even less of a problem. Some insulin analogs, for instance, may be associated with less weight gain. Insulin pumps can help provide the missing hormone more smoothly and accurately, helping to reduce weight gain issues.

Another approach may be smart insulin that turns on when it’s needed to lower blood sugar levels and turns off when blood glucose is at a safe level.

New tablets to increase the loss of glucose into the urine have recently become available for the treatment of type 2 diabetes in Australia. While they are not currently used in type 1 diabetes, studies suggest they can reduce insulin requirements and improve weight control in type 1 diabetes.

Needing to take insulin should not be a barrier to a healthy waistline. Missing or reducing insulin doses is not a solution to weight control. It is understandable, but it is also unsafe.

However, once entrenched, diabulimia can be a hard behaviour to break without extra help. It is hard to own up to not taking your medication. But your doctor and diabetes team will understand and be able to get you the support you need.

For more information, see We Are Diabetes.

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