Diabulimia

Last updated
Diabulimia
Other namesED-DMT1, eating disorder-diabetes mellitus type 1, type 1 eating disorder
Specialty Psychiatry
Symptoms restricting insulin, hyperglycaemia, diabetic ketoacidosis
Complications hyperglycaemia, diabetic ketoacidosis, other symptoms of hyperglycaemia
Durationvariable, can last years
Causes body dysmorphia
Risk factors existing eating disorder (such as anorexia nervosa or bulimia nervosa)
Differential diagnosis type 1 diabetes without an eating disorder
Treatment cognitive behavioural therapy
Prognosis reduced life expectancy
Frequency40% of men and 20% of women with type 1 diabetes
Deathson the increase

Diabulimia (a portmanteau of diabetes and bulimia ), also known as ED-DMT1 (eating disorder-diabetes mellitus type 1) in the US or T1ED (type 1 eating disorder) in the UK, is an eating disorder in which people with type 1 diabetes deliberately give themselves less insulin than they need or stop taking it altogether for the purpose of weight loss. Diabulimia is not recognized as a formal psychiatric diagnosis in the DSM-5. Because of this, some in the medical or psychiatric communities use the phrases "disturbed eating behavior" or "disordered eating behavior" (DEB in both cases) and disordered eating (DE) are quite common in medical and psychiatric literature addressing patients who have type 1 diabetes and manipulate insulin doses to control weight along with exhibiting bulimic behavior.

Contents

Diabulimia is caused by a range of factors relating to body image, the regular use of insulin, and emotional well-being. Insulin can cause weight gain, and a person who restricts insulin may lose weight. Insulin restriction can lead to the common symptoms of uncontrolled hyperglycemia, which risks complications and a shorter life expectancy. Treatment involves cognitive behavioral therapy, and other support services offered by a multidisciplinary team who work both in diabetes medicine and on eating disorders.

Diabulimia is most common in young people, and most of the severe cases tend to occur in women. Research into effective management strategies is ongoing, with a growing medical consensus on the importance of early intervention with specialist teams. People with diabulimia often suffer both from clinicians and from friends and family, partly due to the lack of understanding of the condition.

Signs and symptoms

A person with diabulimia, especially if not treated early, can result in negative effects on the body. Of diabetics who have a DEB, some intentionally misuse insulin to control weight. [1] [2] [3] This may also involve irregular eating patterns. [4] [5]

Suspension of insulin combined with overeating can result in ketoacidosis. [6] [7] Multiple hospitalizations for ketoacidosis or hyperglycemia are cues to screen for an underlying emotional conflict. [2] [8]

Short term

The short-term symptoms of diabulimia are:

Medium term

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

Long term

If a person with type 1 diabetes who has diabulimia has 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:

Causes

Diabulimia

Diabulimia is caused by a range of factors relating to body image, the regular use of insulin, and emotional well-being. [5] [6] The long-term management of type 1 diabetes often involves dietary restrictions for control of blood sugar level, which can raise a negative attention to diet. [4] [6] There is often a focus on the fact that insulin can cause weight gain, and that not using insulin can cause weight loss. [6] [12] For example, a person with type 1 diabetes may have experienced weight loss before the diagnosis, followed by weight gain when beginning treatment with insulin. This may lead to increased body dissatisfaction and preoccupation with weight loss. [13] This increases the risk of eating disorders such as anorexia nervosa and bulimia nervosa. The vast majority of people with diabulimia are aware of the negative side effects that hyperglycemia can cause. [7]

Skipping insulin can lead to weight loss without side effects at first, but the risk of side effects gets progressively worse - by this time, it is more difficult to change behavior. [4] Weight gain can cause individuals to fear insulin as it is often seen as the root of their low self-esteem. Low self-esteem can lead to depression or anxiety about body image that contributes to difficulty with diabetes management. [14]

Often, individuals often think diabulimia is less common than it is and do not know how difficult it is to overcome. Unlike vomiting or starving, there is sometimes no clear action or willpower involved. Often, individuals will refuse to believe in the diagnosis or the long-term effects. [15]

Eating Disorders

Eating disorders can stem from a variety of factors, extending beyond individual predispositions. Influences from Western culture, childhood sexual abuse, specific personality traits, and neurobiological factors are identified as additional contributors to the development of eating disorders.

Western cultural influence plays a significant role, often promoting unrealistic beauty standards and societal pressures related to body image. The pervasive impact of media, emphasizing certain body ideals, can contribute to the development of unhealthy eating patterns.

Childhood sexual abuse is recognized as a traumatic experience that may lead to the development of eating disorders. The psychological effects of such abuse can manifest in disordered eating as individuals cope with emotional distress through their relationship with food.

Certain personality traits, such as perfectionism, low self-esteem, or a strong desire for control, are associated with an increased vulnerability to eating disorders. These traits may influence the way individuals perceive and interact with their bodies and food.

Additionally, emerging evidence in the field of neurobiology suggests that there are biological factors contributing to the development and maintenance of eating disorders. Neurochemical imbalances and alterations in brain function may influence appetite regulation, reinforcing disordered eating behaviors.

Understanding the multifaceted nature of these causes is crucial for comprehensive prevention and treatment strategies. [16]

Prognosis

Diabulimia appears to lower life expectancy compared to other patients with type 1 diabetes, with the mean age of death around 45 (13 years lower than that for type 1 diabetes without an eating disorder). [17] This reduced life expectancy is correlated with the severity of eating disorder behaviors. [17]

Treatment

Treatment for diabulimia has two goals: stabilizing diabetes by increasing insulin intake and addressing the underlying eating disorder. The standard approach for the treatment of two complex conditions involves a multidisciplinary team of professionals. [6] [18] This team may include an endocrinologist, a psychiatrist, a psychologist, and a dietician. [11]

Eating Disorder

To address the underlying eating disorder psychosocial interventions such as cognitive behavioral therapy, motivational therapy, problem-solving therapy, coping skills training, and family behavior therapy have all been shown to improve treatment adherence and achieve good glycemic control. It has been observed that addressing psychological needs improves HbA1c by 0.5%–1% in adults with T2DM. [19] Useful therapies may involve cognitive behavioral therapy. [20] [21] Cognitive behavioral therapy focuses on changing unhealthy thinking surrounding the use of insulin. [9]

Family involvement and family therapy is helpful for long-term maintenance of good behaviors with taking insulin. [11] [22] A positive mindset to recovery, and connection with others who have experienced diabulimia, increases the probability of successful recovery. [22]

Insulin

Individuals diagnosed with type 1 diabetes typically need to administer insulin on a daily basis, frequently four to five injections throughout the day. The methods of insulin injection vary, including the use of a syringe and needle, an insulin delivery pen, or an insulin pump.

Finding the optimal insulin dose to effectively lower one's blood glucose to the desired levels may take some time, even with the assistance of healthcare professionals. This process involves careful adjustment and monitoring to achieve the best outcomes for managing diabetes. [23]

Even with treatment, relapse is common (some estimate over 50% relapse within six years), requiring long-term reassessment for early intervention. [24]

Epidemiology

Diabulimia is most common in women, and in people between 15 and 30 years old. [6] Around 40% of men with type 1 diabetes may have skipped insulin injection at least once, and around 20% of women. [6] [18] Some studies have found that up to 60% of people with type 1 diabetes deliberately restrict insulin at some point. [25]

Many articles and studies further conclude that diabetic females have, on average, higher body mass index (BMI) than their nondiabetic counterparts. Girls and young adult women with higher BMIs are also shown to be more likely to have disordered eating behavior (DEB). [26] [27] Many authoritative articles 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] [27] [28] [3]

History

Diabulimia is not currently recognised in the DSM-5. [29] Current diagnoses are based on the idea of insulin restriction being a feature of existing anorexia nervosa and bulimia nervosa. [29] Diabulimia is gaining notability within scientific research. [7] In 2019, NHS England began trialling specialist diabulimia clinics. [6] [30] Whilst access to eating disorder clinics is improving, access to specialist diabulimia services is not widely available. [21]

Society and culture

A lack of recognition of diabulimia by clinicians leads to generally negative medical interactions. [7] There is also a lack of public awareness. [7] A lack of medical understanding creates social stigma. [7] Because diabulimia tends not to involve significant eating restriction like anorexia nervosa, or purging as in bulimia nervosa, some do not recognise the significance of diabulimia. [11] A BBC documentary in 2017 caused a significant increase in requests for specialist medical training for diabulimia, and improved public awareness. [31] [32]

See also

Related Research Articles

<span class="mw-page-title-main">Diabetic ketoacidosis</span> Medical condition

Diabetic ketoacidosis (DKA) is a potentially life-threatening complication of diabetes mellitus. Signs and symptoms may include vomiting, abdominal pain, deep gasping breathing, increased urination, weakness, confusion and occasionally loss of consciousness. A person's breath may develop a specific "fruity" smell. The onset of symptoms is usually rapid. People without a previous diagnosis of diabetes may develop DKA as the first obvious symptom.

An eating disorder is a mental disorder defined by abnormal eating behaviors that adversely affect a person's physical or mental health. Types of eating disorders include binge eating disorder, where the patient eats a large amount in a short period of time; anorexia nervosa, where the person has an intense fear of gaining weight and restricts food or overexercises to manage this fear; bulimia nervosa, where individuals eat a large quantity (binging) then try to rid themselves of the food (purging); pica, where the patient eats non-food items; rumination syndrome, where the patient regurgitates undigested or minimally digested food; avoidant/restrictive food intake disorder (ARFID), where people have a reduced or selective food intake due to some psychological reasons; and a group of other specified feeding or eating disorders. Anxiety disorders, depression and substance abuse are common among people with eating disorders. These disorders do not include obesity. People often experience comorbidity between an eating disorder and OCD. It is estimated 20–60% of patients with an ED have a history of OCD.

<span class="mw-page-title-main">Hyperglycemia</span> Too much blood sugar, usually because of diabetes

Hyperglycemia is a condition in which an excessive amount of glucose circulates in the blood plasma. This is generally a blood sugar level higher than 11.1 mmol/L (200 mg/dL), but symptoms may not start to become noticeable until even higher values such as 13.9–16.7 mmol/L (~250–300 mg/dL). A subject with a consistent fasting blood glucose range between ~5.6 and ~7 mmol/L is considered slightly hyperglycemic, and above 7 mmol/L is generally held to have diabetes. For diabetics, glucose levels that are considered to be too hyperglycemic can vary from person to person, mainly due to the person's renal threshold of glucose and overall glucose tolerance. On average, however, chronic levels above 10–12 mmol/L (180–216 mg/dL) can produce noticeable organ damage over time.

<span class="mw-page-title-main">Type 2 diabetes</span> Form of diabetes mellitus

Type 2 diabetes (T2D), formerly known as adult-onset diabetes, is a form of diabetes mellitus that is characterized by high blood sugar, insulin resistance, and relative lack of insulin. Common symptoms include increased thirst, frequent urination, fatigue and unexplained weight loss. Symptoms may also include increased hunger, having a sensation of pins and needles, and sores (wounds) that do not heal. Often symptoms come on slowly. Long-term complications from high blood sugar include heart disease, stroke, diabetic retinopathy which can result in blindness, kidney failure, and poor blood flow in the limbs which may lead to amputations. The sudden onset of hyperosmolar hyperglycemic state may occur; however, ketoacidosis is uncommon.

<span class="mw-page-title-main">Bulimia nervosa</span> Type of eating disorder

Bulimia nervosa, also known as simply bulimia, is an eating disorder characterized by binge eating followed by purging or fasting, and excessive concern with body shape and weight. This activity aims to expel the body of calories eaten from the binging phase of the process. Binge eating refers to eating a large amount of food in a short amount of time. Purging refers to the attempts to get rid of the food consumed. This may be done by vomiting or taking laxatives.

Binge eating disorder (BED) is an eating disorder characterized by frequent and recurrent binge eating episodes with associated negative psychological and social problems, but without the compensatory behaviors common to bulimia nervosa, OSFED, or the binge-purge subtype of anorexia nervosa.

Binge eating is a pattern of disordered eating which consists of episodes of uncontrollable eating. It is a common symptom of eating disorders such as binge eating disorder and bulimia nervosa. During such binges, a person rapidly consumes an excessive quantity of food. A diagnosis of binge eating is associated with feelings of loss of control. Binge eating disorder is also linked with being overweight and obesity.

Maturity-onset diabetes of the young (MODY) refers to any of several hereditary forms of diabetes mellitus caused by mutations in an autosomal dominant gene disrupting insulin production. Along with neonatal diabetes, MODY is a form of the conditions known as monogenic diabetes. While the more common types of diabetes involve more complex combinations of causes involving multiple genes and environmental factors, each forms of MODY are caused by changes to a single gene (monogenic). GCK-MODY and HNF1A-MODY are the most common forms.

A food addiction or eating addiction is any behavioral addiction characterized primarily by the compulsive consumption of palatable and hyperpalatable food items. Such foods often have high sugar, fat, and salt contents, and markedly activate the reward system in humans and other animals. Those with eating addictions often overconsume such foods despite the adverse consequences associated with their overconsumption.

<span class="mw-page-title-main">Type 1 diabetes</span> Form of diabetes mellitus

Type 1 diabetes (T1D), formerly known as juvenile diabetes, is an autoimmune disease that originates when cells that make insulin are destroyed by the immune system. Insulin is a hormone required for the cells to use blood sugar for energy and it helps regulate glucose levels in the bloodstream. Before treatment this results in high blood sugar levels in the body. The common symptoms of this elevated blood sugar are frequent urination, increased thirst, increased hunger, weight loss, and other serious complications. Additional symptoms may include blurry vision, tiredness, and slow wound healing. Symptoms typically develop over a short period of time, often a matter of weeks if not months.

The term diabetes includes several different metabolic disorders that all, if left untreated, result in abnormally high concentrations of a sugar called glucose in the blood. Diabetes mellitus type 1 results when the pancreas no longer produces significant amounts of the hormone insulin, usually owing to the autoimmune destruction of the insulin-producing beta cells of the pancreas. Diabetes mellitus type 2, in contrast, is now thought to result from autoimmune attacks on the pancreas and/or insulin resistance. The pancreas of a person with type 2 diabetes may be producing normal or even abnormally large amounts of insulin. Other forms of diabetes mellitus, such as the various forms of maturity-onset diabetes of the young, may represent some combination of insufficient insulin production and insulin resistance. Some degree of insulin resistance may also be present in a person with type 1 diabetes.

The Eating Attitudes Test, created by David Garner, is a widely used 26-item, standardized self-reported questionnaire of symptoms and concerns characteristic of eating disorders. The EAT is useful in assessing "eating disorder risk" in high school, college and other special risk samples such as athletes. EAT has been extremely effective in screening for anorexia nervosa in many populations.

Purging disorder is an eating disorder characterized by the DSM-5 as self-induced vomiting, or misuse of laxatives, diuretics, or enemas to forcefully evacuate matter from the body. Purging disorder differs from bulimia nervosa (BN) because individuals do not consume a large amount of food before they purge. In current diagnostic systems, purging disorder is a form of other specified feeding or eating disorder. Research indicates that purging disorder, while not rare, is not as commonly found as anorexia nervosa or bulimia nervosa. This syndrome is associated with clinically significant levels of distress, and that it appears to be distinct from bulimia nervosa on measures of hunger and ability to control food intake. Some of the signs of purging disorder are frequent trips to the bathroom directly after a meal, frequent use of laxatives, and obsession over one's appearance and weight. Other signs include swollen cheeks, popped blood vessels in the eyes, and clear teeth which are all signs of excessive vomiting.

<span class="mw-page-title-main">Anorexia nervosa</span> Type of eating disorder

Anorexia nervosa (AN), often referred to simply as anorexia, is an eating disorder characterized by food restriction, body image disturbance, fear of gaining weight, and an overpowering desire to be thin.

The differential diagnoses of anorexia nervosa (AN) includes various types of medical and psychological conditions, which may be misdiagnosed as AN. In some cases, these conditions may be comorbid with AN because the misdiagnosis of AN is not uncommon. For example, a case of achalasia was misdiagnosed as AN and the patient spent two months confined to a psychiatric hospital. A reason for the differential diagnoses that surround AN arise mainly because, like other disorders, it is primarily, albeit defensively and adaptive for, the individual concerned. Anorexia Nervosa is a psychological disorder characterized by extremely reduced intake of food. People with anorexia nervosa tend to have a low self-image and an inaccurate perception of their body.

Cognitive behavioral therapy (CBT) is derived from both the cognitive and behavioral schools of psychology and focuses on the alteration of thoughts and actions with the goal of treating various disorders. The cognitive behavioral treatment of eating disorders emphasizes on the minimization of negative thoughts about body image and the act of eating, and attempts to alter negative and harmful behaviors that are involved in and perpetuate eating disorders. It also encourages the ability to tolerate negative thoughts and feelings as well as the ability to think about food and body perception in a multi-dimensional way. The emphasis is not only placed on altering cognition, but also on tangible practices like making goals and being rewarded for meeting those goals. CBT is a "time-limited and focused approach" which means that it is important for the patients of this type of therapy to have particular issues that they want to address when they begin treatment. CBT has also proven to be one of the most effective treatments for eating disorders.

<span class="mw-page-title-main">Diabetes</span> Group of endocrine diseases characterized by high blood sugar levels

Diabetes mellitus, often known simply as diabetes, is a group of common endocrine diseases characterized by sustained high blood sugar levels. Diabetes is due to either the pancreas not producing enough insulin, or the cells of the body becoming unresponsive to the hormone's effects. Classic symptoms include thirst, polyuria, weight loss, and blurred vision. If left untreated, the disease can lead to various health complications, including disorders of the cardiovascular system, eye, kidney, and nerves. Diabetes accounts for approximately 4.2 million deaths every year, with an estimated 1.5 million caused by either untreated or poorly treated diabetes.

Oral manifestations of systematic disease are signs and symptoms of disease occurring elsewhere in the body detected in the oral cavity and oral secretions. High blood sugar can be detected by sampling saliva. Saliva sampling may be a non-invasive way to detect changes in the gut microbiome and changes in systemic disease. Another example is tertiary syphilis, where changes to teeth can occur. Syphilis infection can be associated with longitudinal furrows of the tongue.

Body image disturbance (BID) is a common symptom in patients with eating disorders and is characterized by an altered perception of one's own body.

Body checking is a compulsive behaviour related but not exclusive to various forms of body dysmorphic disorders. It involves frequently collecting various information about one’s own body in terms of size, shape, appearance or weight. Frequent expressions of this form of behaviour entails for example mirror checking, trying to feel one’s own bones, pinching the abdomen, frequent body weight measurement and comparing your own body to that of others. Studies have shown that an increased rate of body checking correlates with an overall increased dissatisfaction with the own body.

References

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