Recognizing and Managing Disordered Eating in Diabetes: What Clinicians Need to Know

Disordered eating behaviors (DEBs) are an often-overlooked challenge in diabetes management. The American Diabetes Association (ADA) now recommends routine screening for disordered eating in both type 1 and type 2 diabetes, using validated, diabetes-specific tools that identify unique behaviors such as intentional insulin omission and binge eating.

Prevalence of Eating Disorders in Type 1 and Type 2 Diabetes

Research shows that people with type 1 diabetes (T1D) have a 2–3 times greater risk of developing an eating disorder than peers without diabetes. Meta-analyses indicate that 24 - 27% of insulin-dependent individuals report symptoms of disordered eating, with about 1 in 5 admitting to insulin restriction or omission—often called “diabulimia.” These behaviors are more frequent in young women and are associated with higher HbA1c levels, recurrent hyperglycemia, and increased rates of diabetic ketoacidosis (DKA).

In type 2 diabetes (T2D), the most common pattern is binge eating disorder (BED), especially among those on insulin therapy. Studies have reported binge eating behaviors in up to 50% of insulin-treated youth and adults. These behaviors correlate with higher body mass index (BMI), depressive symptoms, and poorer glycemic control. Among adolescents with T2D, more than 25% report maladaptive behaviors such as vomiting, skipping insulin, or using diet pills or laxatives—patterns closely tied to obesity severity and emotional distress.

Understanding Why Disordered Eating Develops in Diabetes

The link between diabetes and disordered eating is multifactorial. Beyond psychosocial stressors, there are physiological and treatment-related drivers:

• Insulin therapy and glucose fluctuations disrupt hunger and satiety signals.

• Constant attention to carbohydrate counting and weight can heighten body image concerns.

• Fear of hypoglycemia and diabetes distress add emotional strain.

The ADA warns clinicians to avoid automatically labeling these behaviors as psychiatric disorders. Instead, providers should consider whether metabolic instability, medication effects, or diabetes-related anxiety are contributing to the pattern.

Screening Tools for Eating Disorders in Diabetes

Despite their high prevalence, individuals with diabetes are less likely to access outpatient eating disorder treatment compared to those without diabetes. The ADA recommends proactive screening using diabetes-specific instruments that capture insulin omission and emotional eating behaviors.

For Type 1 Diabetes:

• Diabetes Eating Problem Survey–Revised (DEPS-R): A score of ≥20 should prompt further assessment.

• Eating Disorders Inventory-3 Risk Composite (EDI-3RC): Useful for detecting high-risk attitudes and behaviors.

For Both Type 1 and Type 2 Diabetes:

• Diabetes Eating Problem Survey–10 (DEPS-10): A newer, concise screening tool validated in 679 patients. It achieved an AUC of 0.92 for detecting binge eating disorder. A score of ≥15 identifies elevated risk. DEPS-10 scores correlate with higher BMI, HbA1c, and psychological distress, making it an excellent option for busy clinics.

Screening should be triggered by unexplained hyperglycemia, weight loss, secrecy around eating, or excessive focus on body weight. Clinicians performing assessments should have experience with both diabetes and eating disorders to ensure accuracy and sensitivity.

Best Practices for Treating Disordered Eating in Diabetes

The ADA emphasizes a multidisciplinary, individualized care approach. Effective management requires collaboration between endocrinologists, dietitians, diabetes educators, and behavioral health professionals experienced in diabetes-related eating disorders.

Evidence-based interventions include:

• Cognitive Behavioral Therapy (CBT): Foundational for addressing distorted thoughts around food and insulin use.

• Motivational Interviewing: Helps build patient readiness for change.

• Family-Based and Youth Programs: Initiatives such as STEADY (Support, Therapy, Education, and Diabetes Awareness in Youth) integrate CBT and diabetes education to reduce insulin omission and improve self-management.

• Medical Nutrition Therapy: Focuses on restoring healthy eating patterns and body awareness rather than strict dieting.

For individuals with type 2 diabetes, GLP-1 receptor agonists and dual GIP/GLP-1 agents may also help by reducing appetite and binge frequency, though more data are needed to confirm these benefits.

Why Early Recognition Matters

Unaddressed disordered eating leads to poorer glycemic control, higher DKA risk, increased depression, and reduced quality of life. Integrating screening tools like DEPS-R and DEPS-10 into routine visits allows for early detection and timely referral to mental health support.

By combining metabolic management with compassionate, evidence-based psychological care, clinicians can dramatically improve outcomes. In diabetes, addressing the “how” and “why” of eating is just as critical as managing the “what” and “how much.”

References

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