Living with type 1 diabetes means making countless daily decisions about food, insulin, and blood sugar management. For some people, this constant focus on eating and weight—combined with factors like insulin-related weight gain—can lead them to develop disordered eating behaviors. One particularly dangerous pattern, often called diabulimia, involves restricting or skipping insulin doses as a way to lose weight or prevent weight gain. Over time, this practice can lead to serious physical and mental health complications.

Due to lack of awareness and the secrecy that tends to accompany disordered eating behaviors, it can feel isolating and frightening to face both diabetes and an eating disorder. Luckily, specialized treatment can help people manage their diabetes while also healing their relationship with food and their body. If you or a loved one with diabetes are struggling with diabulimia, know that you're not alone—and that effective help is available.

What is diabulimia?

Diabulimia is a condition in which someone diagnosed with type 1 diabetes intentionally restricts their insulin usage in order to control their weight. It's also known as ED-DMT1, or a dual diagnosis of an eating disorder with type 1 diabetes.

We all need insulin to regulate blood glucose levels and ensure our cells get the energy they need to perform all of their vital roles. People with type 1 diabetes need insulin medication because their pancreas either doesn't make any insulin or doesn't make enough insulin. If they don’t take insulin, their body cannot use any of the nutrients they consume—leading to many serious physical consequences, including weight loss.

It's unclear how many people have diabulimia, however, in general, people with type 1 diabetes are more likely to develop eating disorders than people who don't have the condition. This is especially true for females: according to one review article published in 2024, 20 to 30 percent of girls and up to 40 percent of young women with type 1 diabetes have also experienced diabulimia. Another review of 14 studies published in 2024 reported that about 10 percent of people with diabetes omit or misuse insulin, with the practice being much more common in females than males.

Is diabulimia an eating disorder?

Diabulimia is not an official eating disorder diagnosis in the Diagnostic and Statistical Manual of Mental Disorders (DSM). Instead, insulin mismanagement is classified as a disordered eating behavior.

It’s important to note that diabulimia often occurs alongside other disordered eating behaviors, and shares similarities with certain eating disorders. People who restrict insulin may also restrict food, binge, or purge through vomiting, excessive exercise, or the use of laxatives. And as with eating disorders like anorexia and bulimia, people with diabulimia are trying to control their weight and often overvalue body shape.

Diabulimia may also co-exist with an official eating disorder diagnosis. Research has found that bulimia and binge eating are significantly more prevalent among patients with type 1 diabetes compared to people without diabetes. However, although the name “diabulimia” seems to imply that people with this condition eat large amounts of food and then purge (a defining characteristic of bulimia), that’s not always the case.

What about type 2 diabetes and eating disorders?

Although everyone with type 1 diabetes needs to take insulin medication, not everyone who has type 2 diabetes needs insulin therapy. Still, since diabulimia is characterized by purposely altering one's insulin administration, people with type 2 diabetes who take insulin can develop diabulimia. People with type 2 diabetes can also develop other eating disorders or disordered eating behaviors.

“People with all kinds of diabetes can struggle with all forms of disordered eating and eating disorders,” says Registered Dietitian, Diabetes Educator, and Certified Eating Disorders Specialist Lauren Newman, RD. “Sometimes that looks a little different than somebody who doesn't have diabetes because of the nuance of caring for your body when you have a chronic illness.”

What causes diabulimia?

As with all eating disorders, the cause of diabulimia is multifactorial.

Body image concerns

Physically, insulin treatment often makes people gain weight because their bodies are finally getting the nutrients they need. This weight gain is healthy and necessary, but it can lead people to struggle with body image, become concerned about body size, and attempt to control their weight.

Restrictive diets

“People with diabetes are often instructed to follow very restrictive diets, or they might be told to cut out different food groups or to lose weight to manage their diabetes,” explains Equip Dietitian Lead Tanya Hargrave-Klein, MS, RDN. “If that person is genetically predisposed to eating disorders, those can be triggering factors that then create an energy deficiency, which can set off the diabulimia.”

A desire for control

Mentally, adjusting to living with a lifelong condition is often challenging. “It requires becoming educated, and sometimes you can do everything right in terms of lifestyle changes and still struggle to manage your blood glucose and health effectively,” Hargrave-Klein says. This stress can take a toll, and research shows that some people experience a feeling of lack of control. They may, in turn, manipulate their insulin dosage to feel like they can control something.

A focus on numbers

There's also a medical need to focus on numbers—such as blood sugar levels, A1c levels, carbohydrates, and insulin dosing—as well as food labels. While necessary, in some people, this may snowball into a preoccupation where a person is constantly counting and monitoring what they eat, how much they eat, and when they eat.

Drive for perfectionism

“When you're managing diabetes, you make so many decisions throughout the day about what you're going to eat, what you're going to do with your food, what you're going to do with your insulin, what you're not going to do with your insulin,” Newman says. “This is stressful, then add that there's often pressure and perfection expected from the diabetes world. A lot of people are trying to keep their blood sugars perfect, and you literally see all day long what your levels are doing. We also know that anyone who is very perfectionistic is at a higher risk of eating disorders and disordered eating behaviors.”

Diabulimia symptoms

The symptoms of diabulimia differ depending on how long someone has been restricting their insulin.

Short-term symptoms include:

• Excessive urination (polyuria) with ketone bodies in the urine (ketonuria)
• Increased hunger
• Excessive thirst
• High blood glucose (above 250 mmol/L but less than 600 mmol/L)
• Weakness
• Fatigue
• Poor concentration
• Electrolyte imbalance (high potassium or low sodium)

Medium-term symptoms include:

• Moderate to severe dehydration
• High blood glucose (above 250 mmol/L but less than 600 mmol/L)
• Weight loss
• Muscle atrophy
• Indigestion
• Gastroesophageal reflux disease (GERD or chronic acid reflux)
• Fluid retention (edema)

Due to the consequences of uncontrolled diabetes, long-term diabulimia symptoms include:

• High blood glucose (above 250 mmol/L but less than 600 mmol/L)
• Kidney damage
• Neuropathy (which causes numbness, tingling, or pain)
• Blindness
• Extreme fatigue
• High cholesterol
• Osteoporosis

Signs you or a loved one may have diabulimia

Although you need blood work and other tests to check for many diabulimia symptoms, there are several physical and psychological signs that may indicate you or a loved one have the condition.

Physical signs

• Weight loss
• Increased urination
• Increased thirst
• Irregular or absent menstrual cycles
• Fatigue

Psychological signs

• Changes in eating habits
• Changes in exercise habits
• Increased focus on food, weight, or appearance
• Social withdrawal
• Secrecy or abnormal behaviors before, during, and after eating
• Secrecy around insulin use
• Avoiding or trying to avoid medical appointments
• Anxiety
• Depression
• Irritability

Health risks of diabulimia

Diabulimia comes with serious risks to your physical and mental health. Most of the risks occur because of the effects of reducing or omitting insulin. When insulin levels fall too low, blood sugar can't get into cells, where it's needed as energy for those cells to perform their vital functions. The body then turns to an alternative energy source, breaking down fats into chemical compounds called ketones to use for fuel. This can lead to weight loss—as well as a cascade of negative health consequences.

Physical health risks

Diabetic ketoacidosis (DKA): High levels of ketones can make the blood acidic, which is toxic. Seek medical care immediately if you suspect you or a loved one have DKA.

Diabetic retinopathy: High blood sugar can damage the retina, the layer of the eye that detects light and converts it to signals sent to the brain. This can lead to spots, streaks, vision loss, and, over time, blindness.

Cardiovascular disease: Elevated blood sugar levels damage blood vessels and boost blood pressure, cholesterol levels, and inflammation in the body, All of this increases the risk of heart disease.

Nerve damage (neuropathy): In addition to damaging blood vessels, uncontrolled blood sugar can cause chemical changes in the nerves and interfere with nerve signal transmission. People may experience symptoms such as numbness, tingling, pain, muscle weakness, loss of balance, and other problems that impair daily functioning.

Kidney damage or failure: Damage to small blood vessels in the kidneys means these organs can't function as well to filter blood and remove waste from our bodies. Over time, this can lead to kidney failure.

Death: Diabulimia can be life-threatening. Both insulin restriction alone and the combination of type 1 diabetes with any eating disorder diagnosis increase the risk of death by three times.

Mental health risks

• Stress
• Anxiety
• Depression
• Lower quality of life

What to do if you or a loved one are struggling with diabulimia

If you believe that you or a loved one might have diabulimia, it's vital to seek help, as the condition carries serious consequences and can be life-threatening.

Know that you may need to proactively reach out rather than wait for a doctor to say something, as endocrinologists may not realize what's going on. “People with eating disorders are often very sneaky with their behaviors,” Newman says. “Endocrinologists may see somebody presenting in this way and not understand it's an eating disorder. They just see it as somebody being noncompliant with their insulin, so then the patient gets a lecture about why taking insulin is important, and they're like, 'I know that and I'm still not going to do it.'” In fact, according to research, 87 percent of people with diabulimia understand the serious consequences of their habits—yet they continue restricting insulin.

Because of the lack of awareness of diabulimia among many medical doctors, Hargrave-Klein recommends seeking a consultation with an eating disorders professional. They can assess your physical and psychological health to determine if you or your loved one are experiencing diabulimia or any other eating disorder.

If any disordered eating or eating disorder is confirmed, then it's time to build a comprehensive care team. Since diabulimia affects physical and psychological health as well as eating habits, this often includes endocrinologists, registered dietitians, certified diabetes care and education specialists (CDCES), and mental health professionals. At Equip, we offer individualized, evidence-based eating disorder treatment, and can coordinate with external diabetes specialists for patients navigating diabulimia alongside other disordered eating behaviors.

Here are some providers a diabulimia treatment team may include:

• Endocrinologists help manage and treat diabetes. They develop personalized treatment plans that usually include medication such as insulin as well as lifestyle changes such as adjusting what you eat, finding exercise you enjoy, and learning ways to manage stress. They also monitor blood sugar levels and, if necessary, adjust your treatment to keep your numbers in a healthy range.
• Registered dietitians are a crucial part of any treatment for disordered eating. If you can work with a dietitian with a CDCES certification and experience treating eating disorders, that is ideal, but they may be harder to find. Since these experts understand both diabetes and eating disorders, they can help you create a comprehensive eating plan that supports healthy eating habits and blood glucose control. “They can help you navigate carb counting and thinking about food for diabetes in a way that's more sustainable for you and less disordered,” Newman says.
• Other certified diabetes care and education specialists include nurses, physician assistants, and doctors. They help patients understand diabetes and support them in changing behaviors and following their treatment plan. It’s important that these providers are also informed about eating disorders, or in communication with an eating disorder care team. “We need to educate the diabetes care team about what relapse looks like, how do we manage that, when do we need to bring in an eating disorder team again, and just create general awareness for them, because they likely have other patients who are experiencing diabulimia and it's going under the radar,” Hargrave-Klein says.
• Therapists, psychiatrists, and other mental health professionals can help patients address any anxiety, depression, distorted body image, and other conditions that often accompany diabulimia. No specific type of therapy has been proven to be most effective for treating diabulimia, but in general, family-based therapy (FBT) is the gold standard for treating eating disorders in children, adolescents, and young adults, and there’s some evidence that cognitive behavioral therapy (CBT) helps improve blood sugar control. However, in order for treatment to be effective, therapists need to understand the specific issues associated with insulin omission, researchers say. You may want to search the American Diabetes Association's mental health professional directory to look for providers who specialize in supporting individuals living with diabetes.

In severe cases, patients may need hospitalization to become medically stable. During this time, staff will monitor their insulin usage, eating habits, and any potential compensatory behaviors, such as exercising and vomiting. If necessary, the medical team will administer insulin and use supplementary nutritional drinks or feeding tubes to ensure the patient consumes the nutrients they need.

Whatever your experience with diabetes and disordered eating is, have hope. With the right treatment team, you or your loved one can find freedom from diabulimia and reestablish a positive relationship with your body and food. At Equip, we offer evidence-based treatment that can help you tackle the complexities of diabulimia and any other disordered behaviors you may be navigating.