Art & science diabetes
Diabulimia: how eating disorders
can affect adolescents with diabetes
Davidson J (2014) Diabulimia: how eating disorders can affect adolescents with diabetes.
Nursing Standard. 29, 2, 44-49. Date of submission: May 14 2013; date of acceptance: April 22 2014.
Abstract
Adherence to self-management and medication regimens is required
to achieve optimal blood glucose control in adolescents with type 1
diabetes mellitus. Non-adherence places adolescents at serious risk of
short and long-term health complications. Adherence difficulties may
be exacerbated by concurrent eating disorders. Diabulimia is a term
used to describe the deliberate administration of insufficient insulin
to maintain glycaemic control for the purpose of causing weight loss.
This article explores the concept of diabulimia and the compounding
complications of an eating disorder on maintaining self-management
regimens in adolescents with diabetes.
Author
Jennifer Davidson
Staff nurse, children’s services, Nottingham Children’s Hospital,
Queen’s Medical Centre, Nottingham
Correspondence to: Jennifer.Davidson@nuh.nhs.uk
Keywords
Adolescents, blood glucose control, blood glucose monitoring,
diabetes, diabulimia, eating disorders, glycaemic control, insulin
administration, type 1 diabetes, weight loss
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DIABETES HAS BECOME one of the greatest
health problems in the UK and is currently costing
the NHS more than £10 billion annually (Diabetes
UK 2012a). Medical advances and diabetic
education interventions have been designed to
achieve optimal management of type 1 diabetes
mellitus and to minimise the risk of health
complications and costs to the NHS. However,
adherence to self-management and medication
regimens remains unsatisfactory, particularly
among adolescents (Diabetes UK 2012a). Diabetes
UK, a charity supporting diabetes care in the
UK, has, therefore, advocated the importance of
raising the awareness of risks, preventive measures
and improved management strategies in relation
to diabetes (Diabetes UK 2012a).
Type 1 diabetes affects more than 23,000
young people in the UK and is one of the most
common chronic health conditions in individuals
under the age of 17 years (Thornton 2009,
Diabetes UK 2012a, International Diabetes
Federation (IDF) 2013). This increasingly
common endocrine disorder is most often
diagnosed between the ages of 10 and 14 years
(Diabetes UK 2012a). Recent European figures
indicate a 22% increase in incidence, with a 3%
increase globally, particularly in individuals
below five years of age (Diabetes UK 2012a,
IDF 2013). Overall incidence is expected to
double by 2025 (Diabetes UK 2012a, IDF 2013).
The number of UK children and young people
diagnosed with diabetes is the highest in Europe
(IDF 2013).
The UK has the lowest number of children
achieving optimal blood glucose control
(Department of Health (DH) Diabetes Policy
Team 2007, IDF 2011, Diabetes UK 2012a).
Diabetes UK (2012a) has reported that more
than 140,000 children and young adults display
dangerously high blood glucose levels. Less
than optimum blood glucose control leads to
increasing incidence of long-term complications,
including retinopathy and nephropathy, as well as
microvascular and macrovascular complications
(IDF 2013). Numerous reports suggest more than
80% of children and young people with diabetes
© NURSING STANDARD / RCN PUBLISHING
do not achieve HbA1c (glycated haemoglobin)
levels of below 7.5% (DH Diabetes Policy Team
2007, Diabetes UK 2010a). HbA1c level relates
to the average plasma concentration of glucose
and is used as an indicator of the average blood
glucose level and diabetic control in the 8-12
weeks before testing (Diabetes.co.uk 2014).
Targets for those who do not have diabetes
are 20mmol/mol (4.0-5.9%) and 48mmol/mol
(6.5%) for those with diabetes (Diabetes.co.uk
2014). The National Institute for Health and
Care Excellence (NICE) (2004) allows an upper
limit of 59mmol/mol (7.5%) in adolescents with
diabetes to reduce the risk of diabetes-related
health implications.
Nine per cent of children and young people
with diabetes in the UK experience an episode of
diabetic ketoacidosis (DKA), a life-threatening
emergency, as a result of low blood-insulin levels,
high blood glucose levels and high blood levels of
counter-regulatory hormones, such as cortisol,
glucagon, growth hormones and catecholamines
(Wolfsdorf et al 2009, Diabetes UK 2012b). DKA
occurs when the body is unable to use glucose as
an energy source due to a lack of insulin. The body
breaks down fatty acids as an alternative energy
source. This form of energy release produces toxic,
acidic ketones as by-products, which accumulate
in the blood resulting in acidosis (Wolfsdorf et al
2009, Diabetes UK 2012b). DKA is a major cause
of hospital admission and the leading cause of
morbidity and death in children and adolescents
with type 1 diabetes (Curtis et al 2002, Butalia
et al 2013). With appropriate outpatient treatment
and adherence to self-management regimens,
these eventualities could be avoided in more than
half the cases (Anderson 2009, Fritsch et al 2011).
Where DKA is persistent, it has been suggested
that insulin omission is the most likely cause.
Persistent DKA is a serious problem for the
individuals and their families with the threat
of long-term complications (Frank 2005).
Although effective self-management of type 1
diabetes is possible, it is demanding. It requires
frequent monitoring of blood glucose levels
to achieve a delicate balance of dietary
carbohydrate intake and daily exercise, coupled
with self-administered insulin injections (DH 2007,
Guo et al 2011, IDF 2013). A plethora of education
and cost-effective management interventions
and multidisciplinary support is available to
help young people with diabetes (NICE 2004,
Viklund and Wikblad 2009). Specialist and
school nurses, age-appropriate literature, hospital
appointments, availability of inpatient stays for
diabetes stabilisation and follow-up clinics are
widely available (NICE 2004). However, despite
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all these interventions, an increasing number
of young people ignore diabetes advice and
education, particularly those aged 14 or 15 years
(Hanna et al 2005, Hains et al 2006, Helgeson
et al 2009, Pretorius et al 2010). Education alone
is not enough to encourage behavioural change.
However, it can reduce diabetes management
anxiety and promote coping, which can improve
clinical outcomes (Diabetes UK 2008, Diabetes
UK 2010a, IDF 2011).
The most common factors considered to affect
adherence to diabetic treatment regimens are
listed in Box 1. However, this article focuses
primarily on diabulimia, an increasingly
recognised eating disorder among adolescents
with type 1 diabetes. Diabulimia is a term that is
used to describe the deliberate administration of
insufficient insulin to maintain glycaemic control
for the purpose of causing weight loss. Diabulimia
has not been formally recognised in the medical
arena, has no formal diagnostic criteria and is
often difficult to detect (Hasken et al 2010, Jancin
2011, Shaban 2013). However, its effect on both
the short and long-term health of adolescents
with diabetes is of great clinical importance. It
is, therefore, vital that healthcare professionals
are able to detect and support those affected
appropriately. This article discusses the evidence
regarding factors affecting adolescent adherence
to diabetes treatment regimens, with particular
emphasis on the mismanagement of insulin
administration in adolescents.
Diabulimia among adolescents with
type 1 diabetes
Eating disorders occur in adolescents and young
adults, especially young women in Western
countries, as the drive for thinness becomes
more prevalent (Smith et al 2008). The risk of
BOX 1
Most common factors affecting adherence to
diabetic treatment regimens among adolescents
 Social relationships.
 Peer pressure.
 Increasing independence from the family.
 Increasing time spent away from the family.
 Adolescent social, cognitive and physical
development.
 The onset of puberty with associated hormone
changes.
 Psychological effect of the disease.
 Comorbidity of eating disorders.
(Jones et al 2000, Wolfsdorf et al 2006, Wolfsdorf
et al 2009, Fritsch et al 2011, Tidy 2014)
september 10 :: vol 29 no 2 :: 2014 45
Art & science diabetes
developing an eating disorder is compounded in
adolescents with type 1 diabetes (Jones et al 2000,
Smith et al 2008, Colton et al 2009, Diabetics
With Eating Disorders (DWED) 2010). The
presence of an eating disorder in adolescents with
diabetes has a direct effect on glycaemic control
(Hasken et al 2010, Shaban 2013) and earlier
onset of diabetic complications (Jones et al 2000,
Darbar and Mokha 2008, Hasken et al 2010,
Takii et al 2011).
It has been suggested that rates of eating
disorders are as high as 30% in adolescent females
with diabetes (Jones et al 2000). Jones et al (2000)
undertook a cross-sectional, case-control study of
over 2,000 Canadian participants aged between
12 and 19 years, with and without diabetes,
using self-administered questionnaires to assess
the prevalence of eating disorders in females
with diabetes compared to their peers. The study
showed that those with diabetes were 2.4 times
more likely to have an eating disorder than their
peers who did not have diabetes.
This finding is supported by Smith et al (2008)
and Colton et al (2009) who reported twice the
incidence of eating disorders, at both threshold
and sub-threshold level, in teenagers with
diabetes than their non-diabetic counterparts.
A sub-threshold eating disorder exists when a
set of symptoms does not meet existing eating
disorder criteria (Psych Central News Editor
2011). However, young people aged between
12 and 19 years, as in Jones et al’s (2000) study,
display great developmental variance. With
such developmental variance in the participants,
results could have been affected by cognitive
functioning and understanding of the disease
and its consequences, differing pyschosocial and
environmental pressures and priorities, as well
as varying levels of independence, autonomy and
engagement in risk-taking behaviour related to
age (Smith et al 2008, Court et al 2009). Others
have argued that areas of the brain, for example,
the frontal and parietal lobes – responsible for
planning and self-control – are not developed
fully in younger adolescents, further affecting
their ability to adhere to treatment (Pickrell
2006) potentially skewing data collected. In
addition, Jones et al (2000) focused solely on
females, possibly exaggerating the occurrence of
eating disorders in the general female population.
Although the inclusion of a large number of
individuals without diabetes in the study enabled
comparisons to be made between the two groups,
significantly more female participants without
diabetes (n = 1098) than with the condition
(n = 356) responded, leading the reader to
question how representative the results were.
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There appears to be limited data available on the
prevalence of eating disorders in adolescent boys,
suggesting this area requires further research.
Colton et al (2009) stated that adolescent boys
who have type 1 diabetes, have higher average
body mass indices and a stronger drive to be thin
compared to their peers without diabetes, but that
the incidence of eating disorders appears rare in
this group.
Some authors have suggested that having type 1
diabetes places the individual at increased risk of
developing an eating disorder because of the
treatment requirements and fluctuating weight
before and after diagnosis (Jones et al 2000, NICE
2004, Smith et al 2008, Hasken et al 2010, Takii
et al 2011). A higher body mass index (BMI) due
to such weight gain often occurs in individuals
with diabetes, heightening body dissatisfaction
and increasing the risks of dieting (Colton et al
2009). Takii et al (2011) have further argued that
the effect of diabetes on psychological
development puts the adolescent at risk of
developing an eating disorder.
Binge eating and insulin under-dosing have
been found to be the most common weight
loss methods used by adolescents with type 1
diabetes (Jones et al 2000, Frank 2005, Colton
et al 2009). Smith et al (2008) suggested that
binge eating and inappropriate compensatory
behaviour were common weight-management
strategies that meet the criteria for eating
disorders. Jones et al (2000) found that insulin
omission was the most common weight loss
behaviour among their study participants
with diabetes, with 11% reporting taking less
insulin than prescribed and 42% reporting
insulin misuse.
The unique weight loss strategy provided by
insulin omission as a way of ‘purging’ through
induced glycosuria is thought to increase the
risk of developing eating disorders in young
people with diabetes (Jones et al 2000, Frank
2005, Colton et al 2009, Court et al 2009). Such
purging behaviour has been associated with
impaired metabolic control over time, poor
maintenance of appropriate glycaemic levels
and body weight (Helgeson et al 2009) and even
death (Jones et al 2000). Insulin under-dosing
results in higher mean HbA1c concentrations,
increasing the risk of microvascular
complications, long-term complications affecting
multiple body systems, diabetic retinopathy,
increased risk of DKA and hospitalisation (Jones
et al 2000, Smith et al 2008, Colton et al 2009,
Young-Hyman and Davis 2009).
The process of omitting insulin is reported
to be most common during late teenage years
© NURSING STANDARD / RCN PUBLISHING
and it is suggested that between 30% and 40%
of adolescent and young females omit insulin
regularly to lose weight (Darbar and Mokha
2008, Colton et al 2009, DWED 2010, Hasken
et al 2010, Shaban 2013). This reinforces the
clinical need for a better understanding of
the condition. However, it is also recognised
these figures might be skewed, as a result of
adolescents failing to admit having such issues
during study periods (Diabetes UK 2007).
Further understanding of motives and effective
management strategies to prevent long-term
health complications is imperative for nurses
encountering adolescents with diabetes.
It is important to recognise that not all young
people who do not adhere to insulin regimens
have diabulimia. Insulin omission may not
always be intentional, but might occur when
individuals lack the necessary will and ability
to manage their diabetes care (Colton et al 2009).
It has been identified that children are being
diagnosed with type 1 diabetes at an increasingly
young age (DH Diabetes Policy Team 2007). By
the time they reach mid-adolescence
(age 14-15 years) – the peak age of adherence
difficulty (Hanna et al 2005) – they may have
had the disease for a long time. The chronic
nature of the disease has been identified as a
trigger factor for difficulties such as depression
and anxiety (NICE 2009). Such conditions
can have a compounding effect on adherence,
directly affecting metabolic control, especially
in conjunction with the age-related increased
levels of counter-regulatory hormones (Frank
2005, Colton et al 2009). Together with an
indirect effect through failure to carry out
self-care (Helgeson et al 2009), these factors can
increase the risk of hyperglycaemia (Diabetes UK
2008, Anderson 2009, Guo et al 2011).
Hyperglycaemic episodes result in weight
loss, which can increase the risk of eating
disorders (Bryden et al 2001). While assessing
psychological difficulties affecting care of
children and adolescents with diabetes, Frank
(2005) recognised the effect of depression
on self-management regimens required for
optimal glycaemic control, arguing many
patients with diabetes and depression are
often unable to undertake tasks required to
maintain safe metabolic control. This puts
them at risk of developing short and long-term
complications. Other psychosocial problems
that result in deliberate insulin omission include
embarrassment about blood glucose testing or
insulin administration with others present, fear
of hypoglycaemia and denial of the condition
(Colton et al 2009).
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There is increasing recognition of the influence
of eating disorders such as diabulimia on
poor adherence to treatment regimens among
adolescents with type 1 diabetes. Indeed, there
has been a concerted effort for diabulimia to
be recognised officially in the medical arena
(DWED 2010, Jancin 2011). As stated previously,
diabulimia has not been classified as a mental
health disorder in the UK, which makes it difficult
for healthcare professionals to recognise the
condition and respond appropriately to it. Some
clinicians, particularly in the United States (US),
are beginning to adapt the DSM-IV criteria for
bulimia nervosa and eating disorders, in particular
the ‘inappropriate compensatory purging
behaviours’ under ‘misuse of medications
for weight loss’ (Darbar and Mokha 2008).
However, formal diagnostic criteria are still
lacking (Jancin 2011).
Regardless of diagnosis, it is important to
support the individual in a multidisciplinary
context and stress the importance of dietetic
involvement alongside the medical care of
adolescents with diabetes (DH Diabetes Policy
Team 2007). The introduction of campaigns such
as ‘Type 1 Diabetes: Make the Grade’ (Diabetes
UK 2014), and emphasis, particularly from
charities in the US, to introduce psycho-education
in schools about diabulimia, alongside the teaching
of other eating disorders (Hasken et al 2010), will
hopefully increase understanding of diabulimia
by young people and healthcare professionals
encountering adolescent with diabetes.
The campaign ‘Type 1 Diabetes: Make the
Grade’ (Diabetes UK 2014) has been developed
in accordance with the Children and Families
Bill 2013 (Department for Education 2013). It
is aimed at supporting nurses working in the
educational context and may further shape
and support nursing delivery in school settings,
although its influence on adolescent adherence is
yet to be evaluated. However, it is also important
the voices of young people with diabetes are
heard. Policies such as a diabetes children’s charter
(Diabetes UK 2010b) are being developed and
the opinions of children and adolescents are
increasingly being considered.
Implications for practice
Failure of adolescents with diabetes to adhere
to their treatment regimen is a multi-factorial
problem. Current interventions to manage
such issues are not effective. NICE (2009) has
suggested that further research needs to be
conducted to investigate the effectiveness of
behavioural and social interventions used for
september 10 :: vol 29 no 2 :: 2014 47
Art & science diabetes

the management of anxiety and depression,
eating disorders, behavioural and conduct
disorders and non-adherence to medication
regimens. Adolescence has been identified as
the period of least adherence. However, there
appears to be minimal research on this age
group. Further identification of motives for
non-adherence would emphasise the issues,
allowing for more focused interventions to
be developed. This might result in improved
adherence, lowering the risk of short and
long-term health complications and leading to
more cost-effective schemes being implemented
throughout the NHS.
In this article many of the cited sources are
literature reviews. More empirical studies
would be beneficial in identifying the specific
needs of adolescents. This could help to ensure
contemporaneous research is being used in the
development of services to target this age group.
The increasing number of people being
diagnosed with diabetes and the high morbidity
rates associated with the condition – resulting
in significant cost to the NHS – should serve as
justification for continued research and better
understanding of diabulimia and its effect on
self-management regimens required to achieve
optimal glycaemic control.

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Conclusion
Despite advances in medical treatment and
management for people with diabetes,
long-term complications and hospital admissions
still occur. No definitive reason exists for non-
adherence to diabetes treatment regimens during
adolescence. However, it is important to recognise
that adolescents with type 1 diabetes may be at
particular risk of developing an eating disorder.
The comorbidity of an eating disorder has been
identified as a major factor influencing adherence
to self-management regimens in adolescents with
diabetes. Female adolescents and those exhibiting
psychosocial pathology and weight gain after the
initiation of treatment are most at risk of non-
adherence to self-management regimens. The
unique purging method available to adolescents
with type 1 diabetes may cause them to ignore
medical advice and misuse their insulin to lose
weight. Without adequate intervention adherence
may decrease further, compounding the health
risks and complications. Further understanding
of motives and behaviour should be sought in the
hope of bridging the gap between current practice
and what adolescents with diabetes are facing.
Care for adolescents with type 1 diabetes needs
to be evaluated to improve health outcomes
for these individuals NS

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