Diabulimia

Diabulimia (a portmanteau of diabetes and bulimia) refers to an eating disorder in which people with Type 1 diabetes deliberately give themselves less insulin than they need, for the purpose of weight loss. Diabulimia is not currently recognized as a formal diagnosis by the medical or psychiatric communities. However, the phrases “disturbed eating behavior” or “disordered eating behavior” (DEB in both cases), or disordered eating (DE) are quite common in medical and psychiatric literature which addresses the condition of patients who have Type 1 diabetes and who also intentionally manipulate insulin doses to control weight.

Failure to administer insulin places the body in a starvation state, resulting in breakdown of muscle and fat into ketone bodies and subsequently ketoacids, while at the same time making the body unable to process sugars that have been consumed, so the sugars are excreted in the urine rather than being used by the body for energy or stored as fat. This typically results in significant weight loss but also places the patient at risk of a life-threatening condition known as diabetic ketoacidosis. Prolonged failure to administer insulin results in long-term complications such as diabetic neuropathy. Insulin restriction is associated not only with increased rates of diabetes complications but increased mortality risk as well. Diabetics who restrict insulin die at earlier ages on average than those diabetics who use insulin properly.^[1]

Following a diagnosis of Type 1 diabetes, a patient is prescribed insulin injections, given a controlled diet, and must check blood sugar several times a day. This lifestyle may result in weight gain, which some (particularly teen girls) may be unhappy about. This may lead them to neglect their insulin treatment for the purpose of losing weight.

Often, people with Type 1 diabetes who omit insulin injections will have already been diagnosed with an eating disorder such as anorexia nervosa, bulimia nervosa and/or compulsive eating. In cases where a person with Type 1 diabetes has another eating disorder, there is a tendency to discuss the other eating disorder more openly than they discuss diabulimia, as many people with diabetes are embarrassed or don't want to deal with the reality that they have lost control of their diabetes. These individuals are often not aware that diabulimia is more common than they think and is also very difficult to overcome. Unlike anorexia and bulimia, diabulimia sometimes requires the afflicted individual to stop caring for a medical condition. Unlike vomiting or starving, there is sometimes no clear action or willpower involved. Diabulimia may be more appealing to individuals who want to lose weight and do not want to feel hungry, or do not want to engage in purging via vomiting. Often there is an obsessive compulsive urge to engage in this activity for the purpose of emotional disassociation or a need to satisfy feelings of control.

This condition can be triggered or exacerbated by the need for diabetics to exercise constant vigilance in regard to food, weight and glycemic control. In adolescents the need for parental control over the young diabetic's life, and the increased weight gain that insulin treatment can cause, may play roles in the increased risk for onset of anorexia and/or bulimia. The frustration of managing blood sugars and their subsequent effects on weight and self perception (altered by dealing with a chronic illness) can also be damaging to self esteem and body image.

A person with diabulimia, especially if not caught and treated early, is likely to suffer the negative effects on the body of diabetes earlier than a person with diabetes who is managing their diabetes in a faithful manner. Long-term potential repercussions of diabetes include renal failure, blindness and diabetic neuropathy. With diabulimia there is an increased chance of death. Diabetic ketoacidosis (DKA) is very common in persons with Type 1 diabetes who have diabulimia. This is due to the body's need for a constant supply of energy, which lack of insulin prevents. DKA is a very serious condition that occurs when one doesn't have enough insulin; without treatment it results in death within a very short span of time.

Diabulimia tends to start in adolescence and is more likely to occur in women than men. One can identify a patient as having diabulimia if there are many unexplainable spikes in their Hemoglobin A1c, weight loss, lack of marks from fingerpricks, lack of prescription refills for diabetes medications, and records that do not match the HbA1c.

Symptoms

Note: these are the symptoms that are present with uncontrolled diabetes

Short term

These are the short term symptoms of patients with diabulimia

• Constant urination
• Constant thirst
• Excessive appetite
• High blood glucose levels (often over 600)
• Weakness
• Fatigue
• Large amounts of glucose in the urine
• Inability to concentrate
• Electrolyte disturbance
• Severe ketonuria, and, in DKA, severe ketonemia
• Low sodium levels

Medium term

These are the medium term symptoms of patients with diabulimia. They are prevalent when diabulimia has not been treated and hence also includes the short term symptoms

• Muscle atrophy
• GERD
• Indigestion
• Severe weight loss
• Proteinuria
• Moderate to severe dehydration
• Edema with fluid replacement
• High cholesterol
• Death

Long term

If a person with Type 1 diabetes who has diabulimia suffers from the disease for more than a short time—usually due to alternating phases during which insulin is injected properly, and relapses, during which they have diabulimia—then the following longer-term symptoms can be expected:

• Severe kidney damage
• Blindness
• Severe neuropathy (nerve damage to hands and feet)
• Extreme fatigue
• Edema (during blood sugars controlled phases)
• Heart problems
• High cholesterol
• Osteoporosis
• Death

See also

• Diabetes mellitus
• Bulimia nervosa
• Eating disorder

Causes

Many authoritative articles have been published which show that preteen and teenage girls with Type 1 diabetes have significantly higher rates of eating disorders of all types than do girls without diabetes.^[2][3][4][5]

Many articles and studies further conclude that diabetic females have, on average, higher body mass index (BMI) than do their nondiabetic counterparts. Girls and young adult woman with higher BMIs are also shown to be more likely to have disordered eating behavior (DEB).^[6][7]

Of diabetics who have DEB, a significant number intentionally misuse insulin as a means to control weight.^[8][9][10]

Suspension of insulin, combined with overeating and resulting in ketoacidosis, may be a call for psychological help or attempts to escape unpleasant or undesirable environments. Less frequently, they may be manifestations of suicidal intent. Multiple hospitalizations for ketoacidosis or hypoglycemia are cues to screen for an underlying emotional conflict. Dealing with the feelings brought on by the restrictive regime of diabetes 1 treatment can be overwhelming. In addition, patients may experience anxiety over the possibility of complications developing from diabetes and possible decreased life span.^[3][11]

References

1. ^ Goebel-Fabbri, et al. (2008). "Insulin restriction and associated morbidity and mortality in women with type 1 diabetes.". Diabetes Care MAR (1): 415–9. http://www.mdconsult.com.ezproxy.lib.uwm.edu/das/citation/body/147681508-2/jorg=journal&source=MI&sp=20479074&sid=0/N/20479074/1.html?issn=. 
2. ^ Colton, P. A., Olmsted, M. P., Daneman, D., Rydall, A. C., Rodin, G. M. (2007). "Five-Year Prevalence and Persistence of Disturbed Eating Behavior and Eating Disorders in Girls With Type 1 Diabetes.". Diabetes are 30 (11): 2861–2862. doi:10.2337/dc07-1057. PMID 17698613. http://care.diabetesjournals.org/content/27/7/1654.full. 
3. ^ ^{a b} Alemzadeh, R., MD and Wyatt., MD (2007). Nelson Textbook of Pediatrics, 18th ed. ISBN 9781416056225 141605622X. 
4. ^ Nielsen S (2002). "Eating disorders in females with type 1 diabetes: an update of a meta-analysis. European Eating Disorders Review". European Eating Disorders Review 10 (4): 241. doi:10.1002/erv.474. http://www3.interscience.wiley.com/journal/94517347/abstract?CRETRY=1&SRETRY=0. 
5. ^ Jones J, Lawson ML, Daneman D, Olmsted MP, Rodin G (2000). "Eating disorders in adolescent females with and without type 1 diabetes: cross sectional study". BMJ (Clinical research ed.) 320 (JUN 10): 1563–1566. doi:10.1136/bmj.320.7249.1563. PMC 27398. PMID 10845962. http://www.bmj.com/cgi/content/abstract/320/7249/1563?ijkey=b1e16f46a47a882d693585f3739c6a47f65e92d5&keytype2=tf_ipsecsha. 
6. ^ Domargard A, Sarnblad S, Kroon M, Karlsson I, Skeppner G, Aman J (1999). "Increased prevalence of overweight in adolescent girls with type I diabetes mellitus". Acta Paediatr 88 (11): 1223–1228. doi:10.1080/080352599750030329. PMID 10591423. 
7. ^ Colton, P. A., Olmsted, M. P., Daneman, D., Rydall, A. C., Rodin, G. M. (2007). "Five-Year Prevalence and Persistence of Disturbed Eating Behavior and Eating Disorders in Girls With Type 1 Diabetes". Diabetes Care 30 (11): 2861–2862. doi:10.2337/dc07-1057. PMID 17698613. http://care.diabetesjournals.org/content/27/7/1654.full. 
8. ^ Neumark-Sztainer, Dianne PHD1, Patterson, Joan PHD1, Mellin, Alison PHD1, Ackard, Diann M. PHD2, Utter, Jennifer MPH1, Story, Mary PHD1 and Sockalosky, Joseph MD3 (2002). "Weight Control Practices and Disordered Eating Behaviors Among Adolescent Females and Males With Type 1 Diabetes". DiabetesCare.com 25 (8): 1289–96. doi:10.2337/diacare.25.8.1289. PMID 12145223. http://care.diabetesjournals.org/content/25/8/1289.full.pdf+html. 
9. ^ Alemzadeh, R., MD and Wyatt., MD (2007). Nelson Textbook of Pediatrics, 18th ed. ISBN 9781416056225 141605622X. 
10. ^ Jones J, Lawson ML, Daneman D, Olmsted MP, Rodin G (2000). "Eating disorders in adolescent females with and without type 1 diabetes: cross sectional study". BMJ (Clinical research ed.) 320 (JUN 10): 1563–1566. doi:10.1136/bmj.320.7249.1563. PMC 27398. PMID 10845962. http://www.bmj.com/cgi/content/abstract/320/7249/1563?ijkey=b1e16f46a47a882d693585f3739c6a47f65e92d5&keytype2=tf_ipsecsha. 
11. ^ Jancin, Bruce, Best treatment unclear for disordered eating in type 1 diabetes, 2008 (2008). Best treatment unclear for disordered eating in type 1 diabetes, journal=MDConsult. 

External links

Diabulimia Helpline: http://www.diabulimiahelpline.org The U.S.'s only nonprofit organization dedicated to the recognition and prevention of diabulimia.

Diabetics with Eating Disorders [U.K.] http://www.dwed.org.uk Charity dedicated to recognition and support, based in the UK.

Support Group http://www.new.facebook.com/group.php?gid=20504517571 A support group for those suffering with diabulimia

DiabetesCare.org (Published by the American Diabetes Association) http://care.diabetesjournals.org/search?fulltext=eating+disorders&submit=yes&x=0&y=0

• http://www.timesonline.co.uk/tol/life_and_style/health/features/article2649279.ece a young diabetic woman who has overcome diabulimia.
• In-depth article on diabulimia from Self.com
• Diabulimia... The Eating Disorder that Strikes Diabetic Teens from About.com
• Diabulimia Discussion Group
• http://www.mercksource.net/pp/us/cns/cns_krames_template.jspzQzpgzEzzSzppdocszSzuszSzcnszSzcontentzSzkrameszSz11309_12zPzhtm
• http://www.anred.com/diab.html
• http://www.savvyhealth.com/disp.asp?doc_id=25
• http://www.something-fishy.org/isf/diabetes.php
• A Teenage Girl's Account of Her Diabulimia