Researchers report that 38-40% of people with type 1 diabetes withhold or reduce their insulin doses to enable them to eat with impunity while simultaneously losing or maintaining a lower body weight. For the first time, reducing insulin as a purging mechanism to manipulate body weight has been included in the most recent Diagnostic and Statistical Manual for Psychiatric Disorders (DSM V, 2013) as a criterion for bulimia nervosa.
The author describes a case of a 41-year old woman with type 1 diabetes of 29-years duration, who began a program of healthy eating and consistent exercise to reduce her BMI of 30kg/m2. A weight loss of 10kg occurred and then her weight plateaued. Further weight loss was then achieved by reducing insulin doses resulting in a significantly elevated HbA1c and the patient was referred for psychological therapy.
The focus during 12 sessions of therapy centred around distress tolerance strategies, an awareness of the standards used for self-evaluation, strengthening a positive body image and adaptive strategies to regulate and re-regulate emotions. After 12-months the patient was able to resolve the conflict between food and non-food ways of coping and eating behaviour became more regulated, insulin doses were administered that were appropriate to carbohydrate intake, and HbA1c subsequently reduced.
When weight becomes more important than other markers of health (e.g. HbA1c, mood, healthy eating behaviours) then psychologically vulnerable people can lose their perspective on what is important in their diabetes self-care regimen. By being curious about what patients are doing rather than what they weigh, health professionals may be able to play a pivotal role in assisting patients avoid body dissatisfaction and the pathways to weight reduction that cause harm.