Wil Dubois

This edition of our weekly diabetes advice column Ask D’Mine is pretty heavy duty. Our columnist Wil Dubois (himself a longtime type 1 who works as a community diabetes educator) is faced with a real medical emergency in the form of an eating disorder.

{Got your own questions? Hopefully nothing as grave as today's... Email us at AskDMine@diabetesmine.com}


Ask DMine column

Betty, type 1 from Michigan, asks: I take insulin before food but vomit after eating due to my concern over weight gain, is this dangerous?

{Editor's Note: YIPES! This is one of those questions where the asker is clearly in danger; we reached out to Betty right away advising her to seek medical help. Meanwhile, Wil definitely wanted to address the issue here in our Q&A}

Wil@Ask D’Mine answers: Yes. This is dangerous! You are at risk of epic hypoglycemia because the insulin you took for the meal hangs out in your body for four hours after you inject it, but if you vomit out the food there’s nothing left to soak it up. All that “extra” insulin will drive your blood sugar low.

In theory, low enough to kill you.

So what to do? I’d say you should take either no insulin at all, or a small percentage of your bolus for any meal you plan to not let digest. What percent depends on how long after you eat that you vomit.

Of course, a lot of folks will want me to talk to you about your eating disorder, which is formally called Bulimia Nervosa, but really, I just want you safe. So I'm not going to get into how to recover from an eating disorder, but rather how to survive one when you have diabetes. 

Because staying safe using insulin—and upchucking to stay thin—are two completely separate things.

How to Bolus for Bulimia

If you vomit immediately after eating, I doubt too many carbs will have made it into your blood stream. You could probably get away with no bolus at all. But if you’re waiting, say, 30 minutes, as a type 1 diabetic you’re going to need some insulin to deal with the portion of the meal you’ve digested.

How to decide how much you need?

Oddly (wink, wink), Lilly and Novo don’t seem to have any advice for us on how to use their products in this way, so we are on our own in uncharted territory—or if someone else has already charted the way, I can’t find their map.

Bearing in mind that I’ve never done this personally, I think a time-based formula will be your best bet. If you generally wait an hour to vomit, then I’d say take a quarter of the “normal” amount of insulin. If you wait 30 minutes, then take an eighth.

How on earth did I choose those numbers? With a dartboard, Ouija Board, and a surf board as sounding boards.

Yeah, I guessed.

But it’s an educated guess based on my knowledge of insulin action curves and human anatomy. Still, it’s only a starting point. You’re going to need to fine-tune it. More on that in a moment. Now, if you want to be more scientific about it—and the more scientifically we approach our diabetes, the better we will do—you could add a more precise time-to-purge formula to your bolus calculations.

I can feel many of you rolling your eyes as I dive in to math again, so I’ll be quick about it.

Count your carbs for the meal like you were taught to, being sure to consider portion size, 

Bulimia Cycle

subtracting the fiber, and all of that. Then divide by 240. This rather small number is roughly your carbs-per-minute absorption based on a four-hour insulin run. Multiply that number by the number of minutes you generally wait to vomit: this gives you the number of carbs you’re likely to absorb, and that’s what you should bolus for.

Math lesson over.

Of course, you are going to have to experiment using your glucometer to fine-tune the approach. Test before the aborted meal, then again at four hours after the first bite. You know you bolused right if the blood sugar at the fourth hour is similar to the starting blood sugar. If it’s lower, adjust your insulin downwards. If it’s higher, you need more insulin.

Ah. I see the pitch fork-bearing mob has arrived at my comment door! Half of them are upset at the advice I just gave you. The other half are upset that I gave you any advice at all.

OK, for those of you who have qualms with my approach, saying the food will digest more quickly than four hours, bear in mind that what I’m trying to do is match the insulin action to the dietary approach and avoid a low blood sugar from a partial meal. To do that, we want as much insulin as possible without causing a low in the four-hour action window. If you’ve got a better idea of how to do that, I’m all ears.

For those of you who don’t think we should be giving this kind of advice in the first place, please keep your judgmental opinions to yourselves. I’m here to give no-holds-barred diabetes advice, and any and all questions are welcome and respected -- especially when people are in desperate circumstances and need help.

Secrets have no place in diabetes control.

A Real Threat

To be clear, it's not that I don't care about the whole throwing up thing; I’m just overly diabetes-focused, and it’s my sworn duty to make sure that first and foremost your diabetes does not hurt you. And in this case it can. I also believe that the worst thing someone like me could do, when someone like you reaches out, is to lecture you about your behavior, or try to get you to change who and what you are. That wouldn’t help you.

But that said, vomiting after eating on a regular basis is actually a serious health issue, and I’d be a poor healthcare worker if I didn’t at least mention the second line dangers.

The simple fact is that your body isn’t engineered for frequent intentional purging. All that stomach acid coming up with your most recent meal can damage the lining of your esophagus, and can lead to a rupture. The acid will also eat away at your teeth, giving you that same charming smile “crack heads” have. Don’t believe me? Stained, discolored teeth are Bulimia Tooth Decay
one of the things docs look for as a warning sign of bulimia. But most dangerous of all, binging and purging leads to electrolyte imbalances which trigger irregular heart beats, possibility leading to heart failure, death, and all of that.

It does neither of us any good to have you safe from your insulin but dead from heart failure. Something to think about. Later.

First bolus safely. Later, think about whether this is the right lifestyle for you.

And speaking of lifestyle, bulimia used to be considered exactly that, although modern research shows that the condition has a strong genetic component. While some people find it gross, others find it effective and bulimia even has its own online support community, just like us D-folks. Check out this vomit advice blog post, and don’t miss the enviably long comment chain at the end that’s a mix of support, appreciation, and extraordinarily judgmental attacks by “outsiders.” Wow, if you think the food fights in our own community are nasty, you ain’t seen nothing yet!

Oh, speaking of diabetes and bulimia, I forgot to mention that data shows that eating disorders are more common among D-ladies than among their sugar-normal sisters. Yes, having diabetes is like having a loaded gun pointed at your head when it comes to every other problem under the sun. But don’t kid yourself that bulimia is just for girls. It affects both sexes, and people of all ages.

So that’s it. Please bolus safe, and thanks for reaching out to me with your question and being willing to share. I bet there are a lot of other ladies (and probably some men) just like you who want to know how to bolus for bulimia, but just didn’t have the courage to ask.

This is not a medical advice column. We are PWDs freely and openly sharing the wisdom of our collected experiences — our been-there-done-that knowledge from the trenches. But we are not MDs, RNs, NPs, PAs, CDEs, or partridges in pear trees. Bottom line: we are only a small part of your total prescription. You still need the professional advice, treatment, and care of a licensed medical professional.
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This content is created for Diabetes Mine, a consumer health blog focused on the diabetes community. The content is not medically reviewed and doesn't adhere to Healthline's editorial guidelines. For more information about Healthline's partnership with Diabetes Mine, please click here.