Diabulimia and Eating Disorders in Type 1 Diabetes with Dr. Liana Abascal

Podcast Summary:

Taking Control Of Your Diabetes® – The Podcast!
Episode: Diabulimia and Eating Disorders in Type 1 Diabetes with Dr. Liana Abascal
Hosts: Dr. Jeremy Pettus & Dr. Steve Edelman
Guest: Dr. Liana Abascal, Clinical Health Psychologist
Release Date: May 26, 2025

Episode Overview

This episode delves into the serious, often-misunderstood intersection of type 1 diabetes and eating disorders, with a special focus on diabulimia. Hosts Dr. Jeremy Pettus and Dr. Steve Edelman are joined by Dr. Liana Abascal, a clinical health psychologist specializing in both diabetes and eating disorders. Together, they explore the prevalence, mechanisms, psychological factors, treatment approaches, and resources for people struggling with diabulimia and related issues. The conversation is candid, empathetic, and practical, aiming to foster greater awareness and hope for patients and clinicians alike.

Key Discussion Points & Insights

1. Defining Diabulimia and Related Eating Disorders

Clarification on Terminology
- Diabulimia: Not the same as bulimia. Involves deliberately omitting or minimizing insulin doses to lose weight, not induced vomiting. (05:21–05:29)
  - “Diabulimia is people who do not take their insulin or minimize their insulin.” – Dr. Liana Abascal (05:21)
- Bulimia: Inducing vomiting or over-exercising as compensatory behaviors.
Overlap and Complexity
- Some individuals may combine insulin omission with other compensatory behaviors (vomiting, overexercise). (05:46–06:19)
Other Disorders
- Anorexia can present in people with type 1 who take insulin as prescribed but severely restrict food intake.

2. Prevalence and Risk Factors

Higher Risk in Type 1 Diabetes
- General population prevalence of eating disorders: 1–5%; risk doubles for those with type 1 diabetes. (04:02–04:44)
  - “Someone who has type 1 is at a twofold risk of developing an eating disorder.” – Dr. Liana Abascal (04:15)
- Constant attention to food and numbers, societal pressures, and the “tool” of insulin omission create a perfect storm.
- Mostly seen in women, but not exclusively.

3. Psychological and Behavioral Dynamics

Ambivalence and Barriers to Treatment
- Many patients endure years of struggle before seeking help, often due to fear of weight gain, stigma, and past insensitive medical encounters. (07:38–09:07)
  - “There’s a lot of ambivalence with eating disorders because people, of course, they want to be healthy and at the same time, gaining, potentially gaining weight is really aversive to them.” – Dr. Liana Abascal (07:52)
Shame, Denial, and Non-Disclosure
- Patients may hide their behaviors, sometimes even from therapists.
  - “I have patients lie to me all the time, and I tell them, I know you’re gonna lie to me. And I love confessions.” – Dr. Liana Abascal (32:23)
Comorbid Psychiatric Issues
- High rates of depression, anxiety, substance use, trauma, and PTSD among patients with eating disorders and type 1 diabetes. (18:09–18:45)

4. Medical Consequences

Immediate and Long-term Risks
- Insulin omission can result in DKA, hospitalizations, and rapid development of diabetes complications (retinopathy, neuropathy, kidney disease). (06:29–16:41)

5. Approaches to Treatment

Multidisciplinary, Gradual, and Individualized
- Combination of psychological therapy and behavioral steps. Emphasis on small, manageable increments in insulin dosing.
  - Example: Increase by just 0.5 units/week to avoid overwhelming psychological distress and manage side effects (like insulin edema). (10:18–12:19)
  - “It will literally be like, this week, you will take a half unit more than what you typically do.” – Dr. Liana Abascal (10:37)
- Exposure therapy model: Gradually increasing tolerance for weight and insulin changes.
- Team-based care: Endocrinologist, psychologist, primary care provider, dietitian, sometimes a psychiatrist. (18:45–18:59)
Addressing Acute and Less Tangible Motivations
- Sometimes, practical consequences (loss of driving privileges, academic withdrawal, or risk of erectile dysfunction) motivate change more effectively than long-term complications.
  - “We really don’t want you to smoke because you’re going to get lung disease and other things, but that may not compel you to make a difference. But not being able to perform well, that might compel you.” – Dr. Liana Abascal (14:12)
Role of Diabetes Technology
- Hybrid closed-loop systems may reduce mental burden, but could be anxiety-provoking for those reluctant to relinquish control. (21:26–24:23)
- CGMs can help or hinder, depending on response to data (motivating vs. triggering obsessive tendencies). (24:35–25:24)
- Emphasis on “safety first”: Encouraging at least baseline insulin coverage to avoid DKA (basal insulin as a first step). (25:58–26:25)

6. Pharmaceuticals and Weight Loss Trends

GLP-1 Agonists & Compounded Medications
- People seek GLP-1s (“designer/compounding pharmacies”) even without medical indication, showing the extent of weight loss pressures. Risk–benefit must be evaluated. (15:47–17:49)
New Long-acting Insulins
- Once-weekly insulins may help with adherence but can increase anxiety due to “huge” single-dose requirements. (27:11–27:53)

7. Practical Resources and Accessing Care

Where to Start
- Diabulimia Hotline, ADA’s mental health provider directory (specialized training in diabetes and eating disorders).
- Insurance coverage can be a challenge; PPOs and “single case agreement” strategies sometimes help. (29:02–30:12)
  - “There is a code that is basically psychological issue that is affecting medical disease, so you can use that in addition to whether it’s eating disorders or depression or other things.” – Dr. Liana Abascal (30:39)
Dr. Abascal’s Practice
- Private practice in California (telehealth available within state). Dr. Abascal’s website is listed in show notes. (33:08–33:28)

Memorable Quotes & Moments

On the Complexity:
“If someone has underlying risk factors for developing an eating disorder and then they develop type one, it really can create a perfect storm.” – Dr. Liana Abascal (04:20)
On Gradual Change:
“We have to really work on tolerating that. Right. Like we do. It’s really exposure treatment is what we’re doing.” – Dr. Liana Abascal (11:32)
On Motivation:
“Sometimes it seems like something will break through. Do you find that to be true?” – Dr. Jeremy Pettus (13:58)
“There’s a term in public health called wrong reason advertising… That may not compel you to make a difference. But not being able to perform well, that might compel you.” – Dr. Liana Abascal (14:12)
On Team Approach:
“With eating disorders there’s very much a team approach. And when someone has diabetes, then of course you want the endocrinologist involved as well.” – Dr. Liana Abascal (18:59)
On Patient Secrecy:
“The average person who’s not taking their insulin, who doesn’t want to take it in order to lose weight, isn’t going to tell you… There’s that trust that needs to be built up.” – Dr. Liana Abascal (32:03)

Success Stories & Hopeful Takeaways

Recovery Stories
- Example of a dancer with type 1 and anorexia who recovered and proactively developed non-triggering carb-counting strategies (20:56–22:06)
- Gradual, supportive insulin increases helping a young woman reverse dangerous omission habits and see improved health. (22:08–23:36)
Key Message
- Struggles with diabulimia and eating disorders in type 1 diabetes are common; shame and isolation are barriers, but recovery is possible with targeted, compassionate support.
  
  “Treatment is available. People can get better. There is kind of a way out of this.” – Dr. Jeremy Pettus (31:02)

Useful Timestamps

00:20–03:45: Framing the issue; guest introduction
03:46–07:11: Defining disorders and prevalence
09:07–12:19: Treatment approaches, behavior and psychology
13:33–16:41: Benefits, motivation, medication trends
18:09–19:22: Comorbid psychiatric illnesses, team-based care
19:28–24:23: Patient stories, the role of technology
25:58–27:53: Basal insulin, long-acting insulins
28:11–30:39: Accessing therapy, insurance insights
31:02–33:28: Conclusions, resources, hope

Resources Mentioned:

Podcast Summary:

Episode Overview

Key Discussion Points & Insights

1. Defining Diabulimia and Related Eating Disorders

Clarification on Terminology
- Diabulimia: Not the same as bulimia. Involves deliberately omitting or minimizing insulin doses to lose weight, not induced vomiting. (05:21–05:29)
  - “Diabulimia is people who do not take their insulin or minimize their insulin.” – Dr. Liana Abascal (05:21)
- Bulimia: Inducing vomiting or over-exercising as compensatory behaviors.
Overlap and Complexity
- Some individuals may combine insulin omission with other compensatory behaviors (vomiting, overexercise). (05:46–06:19)
Other Disorders
- Anorexia can present in people with type 1 who take insulin as prescribed but severely restrict food intake.

2. Prevalence and Risk Factors

Higher Risk in Type 1 Diabetes
- General population prevalence of eating disorders: 1–5%; risk doubles for those with type 1 diabetes. (04:02–04:44)
  - “Someone who has type 1 is at a twofold risk of developing an eating disorder.” – Dr. Liana Abascal (04:15)
- Constant attention to food and numbers, societal pressures, and the “tool” of insulin omission create a perfect storm.
- Mostly seen in women, but not exclusively.

3. Psychological and Behavioral Dynamics

Ambivalence and Barriers to Treatment
- Many patients endure years of struggle before seeking help, often due to fear of weight gain, stigma, and past insensitive medical encounters. (07:38–09:07)
  - “There’s a lot of ambivalence with eating disorders because people, of course, they want to be healthy and at the same time, gaining, potentially gaining weight is really aversive to them.” – Dr. Liana Abascal (07:52)
Shame, Denial, and Non-Disclosure
- Patients may hide their behaviors, sometimes even from therapists.
  - “I have patients lie to me all the time, and I tell them, I know you’re gonna lie to me. And I love confessions.” – Dr. Liana Abascal (32:23)
Comorbid Psychiatric Issues
- High rates of depression, anxiety, substance use, trauma, and PTSD among patients with eating disorders and type 1 diabetes. (18:09–18:45)

4. Medical Consequences

Immediate and Long-term Risks
- Insulin omission can result in DKA, hospitalizations, and rapid development of diabetes complications (retinopathy, neuropathy, kidney disease). (06:29–16:41)

5. Approaches to Treatment

Multidisciplinary, Gradual, and Individualized
- Combination of psychological therapy and behavioral steps. Emphasis on small, manageable increments in insulin dosing.
  - Example: Increase by just 0.5 units/week to avoid overwhelming psychological distress and manage side effects (like insulin edema). (10:18–12:19)
  - “It will literally be like, this week, you will take a half unit more than what you typically do.” – Dr. Liana Abascal (10:37)
- Exposure therapy model: Gradually increasing tolerance for weight and insulin changes.
- Team-based care: Endocrinologist, psychologist, primary care provider, dietitian, sometimes a psychiatrist. (18:45–18:59)
Addressing Acute and Less Tangible Motivations
- Sometimes, practical consequences (loss of driving privileges, academic withdrawal, or risk of erectile dysfunction) motivate change more effectively than long-term complications.
  - “We really don’t want you to smoke because you’re going to get lung disease and other things, but that may not compel you to make a difference. But not being able to perform well, that might compel you.” – Dr. Liana Abascal (14:12)
Role of Diabetes Technology
- Hybrid closed-loop systems may reduce mental burden, but could be anxiety-provoking for those reluctant to relinquish control. (21:26–24:23)
- CGMs can help or hinder, depending on response to data (motivating vs. triggering obsessive tendencies). (24:35–25:24)
- Emphasis on “safety first”: Encouraging at least baseline insulin coverage to avoid DKA (basal insulin as a first step). (25:58–26:25)

6. Pharmaceuticals and Weight Loss Trends

GLP-1 Agonists & Compounded Medications
- People seek GLP-1s (“designer/compounding pharmacies”) even without medical indication, showing the extent of weight loss pressures. Risk–benefit must be evaluated. (15:47–17:49)
New Long-acting Insulins
- Once-weekly insulins may help with adherence but can increase anxiety due to “huge” single-dose requirements. (27:11–27:53)

7. Practical Resources and Accessing Care

Where to Start
- Diabulimia Hotline, ADA’s mental health provider directory (specialized training in diabetes and eating disorders).
- Insurance coverage can be a challenge; PPOs and “single case agreement” strategies sometimes help. (29:02–30:12)
  - “There is a code that is basically psychological issue that is affecting medical disease, so you can use that in addition to whether it’s eating disorders or depression or other things.” – Dr. Liana Abascal (30:39)
Dr. Abascal’s Practice
- Private practice in California (telehealth available within state). Dr. Abascal’s website is listed in show notes. (33:08–33:28)

Memorable Quotes & Moments

On the Complexity:
“If someone has underlying risk factors for developing an eating disorder and then they develop type one, it really can create a perfect storm.” – Dr. Liana Abascal (04:20)
On Gradual Change:
“We have to really work on tolerating that. Right. Like we do. It’s really exposure treatment is what we’re doing.” – Dr. Liana Abascal (11:32)
On Motivation:
“Sometimes it seems like something will break through. Do you find that to be true?” – Dr. Jeremy Pettus (13:58)
“There’s a term in public health called wrong reason advertising… That may not compel you to make a difference. But not being able to perform well, that might compel you.” – Dr. Liana Abascal (14:12)
On Team Approach:
“With eating disorders there’s very much a team approach. And when someone has diabetes, then of course you want the endocrinologist involved as well.” – Dr. Liana Abascal (18:59)
On Patient Secrecy:
“The average person who’s not taking their insulin, who doesn’t want to take it in order to lose weight, isn’t going to tell you… There’s that trust that needs to be built up.” – Dr. Liana Abascal (32:03)

Success Stories & Hopeful Takeaways

Recovery Stories
- Example of a dancer with type 1 and anorexia who recovered and proactively developed non-triggering carb-counting strategies (20:56–22:06)
- Gradual, supportive insulin increases helping a young woman reverse dangerous omission habits and see improved health. (22:08–23:36)
Key Message
- Struggles with diabulimia and eating disorders in type 1 diabetes are common; shame and isolation are barriers, but recovery is possible with targeted, compassionate support.
  
  “Treatment is available. People can get better. There is kind of a way out of this.” – Dr. Jeremy Pettus (31:02)

Useful Timestamps

00:20–03:45: Framing the issue; guest introduction
03:46–07:11: Defining disorders and prevalence
09:07–12:19: Treatment approaches, behavior and psychology
13:33–16:41: Benefits, motivation, medication trends
18:09–19:22: Comorbid psychiatric illnesses, team-based care
19:28–24:23: Patient stories, the role of technology
25:58–27:53: Basal insulin, long-acting insulins
28:11–30:39: Accessing therapy, insurance insights
31:02–33:28: Conclusions, resources, hope

Resources Mentioned:

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Summary

Podcast Summary:

Episode Overview

Key Discussion Points & Insights

1. Defining Diabulimia and Related Eating Disorders

2. Prevalence and Risk Factors

3. Psychological and Behavioral Dynamics

4. Medical Consequences

5. Approaches to Treatment

6. Pharmaceuticals and Weight Loss Trends

7. Practical Resources and Accessing Care

Memorable Quotes & Moments

Success Stories & Hopeful Takeaways

Useful Timestamps

Summary

Podcast Summary:

Episode Overview

Key Discussion Points & Insights

1. Defining Diabulimia and Related Eating Disorders

2. Prevalence and Risk Factors

3. Psychological and Behavioral Dynamics

4. Medical Consequences

5. Approaches to Treatment

6. Pharmaceuticals and Weight Loss Trends

7. Practical Resources and Accessing Care

Memorable Quotes & Moments

Success Stories & Hopeful Takeaways

Useful Timestamps