Type 1 diabetes is one of most common chronic diseases of childhood and adolescence.  In the first major national analysis of diabetes trends among American youth, presented at the June 2012 American Diabetes Association Scientific Meeting, researchers reported an alarming 23% rise in type 1 diabetes over an eight-year period ending in 2009.
Funded by the Centers for Disease Control and Prevention and the National Institutes for Health, the study used data from 20,000 children and youth under 20 at multiple hospitals and health centers in five states.  While the cause of type 1 diabetes remains unknown, the growing rate of incidence has implications for Emergency Physicians.

Although treatment of type 1 diabetes has made progress in prevention of such complications as diabetic ketoacidosis, one “side effect” of successful treatment is weight gain.  Type 1 diabetes requires stringent dietary compliance as part of medical management.  Patients eat according to a meal plan that optimizes blood glucose levels, rather than relying on internal hunger signals.  The need for a regulated diet, along with the required insulin therapy, may result in a BMI higher than that in a non-diabetic. (1)

For type 1 diabetic adolescents, especially girls, an increased BMI puts them at high risk to develop a pattern of frequent dieting, binge eating and purging, excessive exercise, and/or disordered eating or eating disorders.  Diabetes offers a unique and convenient method of weight loss and control: deliberate omission of insulin, unofficially called “diabulimia”.  (2) Both insulin omission and insulin dose manipulation provide teens with a unique way to purge.  The body compensates for the high blood sugars through frequent urination and loss of calories in the urine. 

In a society that values being thin, adolescents are particularly vulnerable to the pressures of conforming to unrealistic standards.  Studies have shown that children living with chronic illness report higher body dissatisfaction and engaged in more high-risk weight loss behaviors than children without chronic illness.  Teens with diabetes who were dissatisfied with their weight or perceived that they were heavier than their peers reported using weight-control methods such as skipping meals, omitting insulin, or taking less insulin. (3) 

According to the American Diabetes Association, an estimated 10 to 20 percent of females with diabetes in their mid-teens and 30 to 40 percent of late teens and young adults will demonstrate diabulimic behavior.  Uncontrolled blood sugar—even short term—can lead to earlier diabetic complications, particularly retinopathy.  In a 4-year follow-up of diabetic girls (ages 12-18 at the start of the study) there was threefold difference in the prevalence of retinopathy between those with highly disordered eating and those without. (86% vs. 24%) The study concluded that “Disordered eating status was, in fact, more predictive of diabetic retinopathy at the time of follow-up, than was the duration of diabetes, a well-established risk factor for microvascular complications.” (4)

Clinicians may want to consider disordered eating behaviors with type 1 diabetic adolescents who present with:

• Repeated episodes of diabetic ketoacidosis
• Unexplained elevated HbA1c levels
• Frequent severe low blood sugar
• Anxiety or avoidance of being weighed
• Delay in puberty or sexual maturation; Irregular or no menses
• Exercising more than necessary to stay fit
• Severe family stress (5)

Diabetes is a complex disease, affecting all aspects of childhood and adolescent life.  The need to focus constantly on food is unavoidable and may lead to a variety of methods to counter weight gain, including diabulimia and other disordered eating practices.  The consequences of attempting weight control through unhealthy and risky behaviors are severe and lifelong.  Emergency Physicians may be able to recognize these patterns and provide an appropriate intervention.

1. Engstrom I, Kroon M, Arvidsson CG, Segnestam K, Snellman K, Aman J.  Eating disorders in adolescent girls with insulin-dependent diabetes mellitus; a population-based case-control study.  Acta Paediatr 1999; 88:117-119.
2. Ruth-Sahd LA, Schneider M, Haagen B.  Diabulimia:  What it is and how to recognize it in critical care. Dimensions in Critical Care Nursing 209, 28:  147-153.
3. Neumark-Sztainer D, Story M, Falkner NH, Beuhring T, Resnick MD. Does body satisfaction matter?  Five-year longitudinal associations between body satisfaction and health behaviors in adolescent females and males.  Journal of Adolescent Health 2006; 39(2), 244-251.
4. Diabetes Control and Complications Trial/Epidemiology of Diabetes Interventions and Complications Research Group.  Retinopathy and nephropathy in patients with type 1 diabetes four years after a trial of intensive therapy. N Engl J Med 2000; 342:381-389.
5. Davidson NK, Moreland P.  Mayo Clinic, Living with Diabetes Blog. Diabulimia:  Recognize this eating disorder.  2011:  June 11.