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.

Diabulimia
Other namesED-DMT1, eating disorder-diabetes mellitus type 1, type 1 eating disorder
SpecialtyPsychiatry
Symptomsrestricting insulin, hyperglycaemia, diabetic ketoacidosis
Complicationshyperglycaemia, diabetic ketoacidosis, other symptoms of hyperglycaemia
Durationvariable, can last years
Causesbody dysmorphia
Risk factorsexisting eating disorder (such as anorexia nervosa or bulimia nervosa)
Differential diagnosistype 1 diabetes without an eating disorder
Treatmentcognitive behavioural therapy
Prognosisreduced life expectancy
Frequency40% of men and 20% of women with type 1 diabetes
Deathsunknown

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 hyperglycaemia, which risks complications and a shorter life expectancy. Treatment involves cognitive behavioural 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 symptomsEdit

A person with diabulimia, especially if not treated early, can result in negative effects on the body earlier than one who is managing properly. 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 termEdit

The short-term symptoms of diabulimia are:

Medium termEdit

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 termEdit

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:

CausesEdit

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][11] 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 hyperglycaemia 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 behaviour.[4]

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, or EDNOS. These individuals often think diabulimia is less common than it is and do not know how difficult it is to overcome. Unlike anorexia and bulimia, diabulimia sometimes requires the affected individual to stop caring for a medical condition. Unlike vomiting or starving, there is sometimes no clear action or willpower involved.

PrognosisEdit

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).[12] This reduced life expectancy is correlated with the severity of eating disorder behaviours.[12]

TreatmentEdit

There are no specific guidelines for the treatment of diabetes and disordered eating. The standard approach for treatment of two complex conditions involves a multidisciplinary team of professionals.[6][13] This team may include an endocrinologist, a psychiatrist, a psychologist, and a dietician.[10] Therapies may involve cognitive behavioural therapy.[14][15] Family involvement and family therapy is helpful for long-term maintenance of good behaviours with taking insulin.[10][16] A positive mindset to recovery, and connection with others who have experienced diabulimia, increases the probability of successful recovery.[16] Even with treatment, relapse is common (some estimate over 50% relapse within 6 years), requiring long-term reassessment for early intervention.[17]

EpidemiologyEdit

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][13] Some studies have found that up to 60% of people with type 1 diabetes deliberately restrict insulin at some point.[18]

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).[19][20] 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][20][21][3]

HistoryEdit

Diabulimia is not currently recognised in the DSM-5.[22] Current diagnoses are based on the idea of insulin restriction being a feature of existing anorexia nervosa and bulimia nervosa.[22] Diabulimia is gaining notability within scientific research.[7] In 2019, NHS England began trialling specialist diabulimia clinics.[6][23] Whilst access to eating disorder clinics is improving, access to specialist diabulimia services is not widely available.[15]

Society and cultureEdit

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.[10] A BBC documentary in 2017 caused a significant increase in requests for specialist medical training for diabulimia, and improved public awareness.[24][25]

See alsoEdit

ReferencesEdit

  1. ^ Neumark-Sztainer D, Patterson J, Mellin A, Ackard DM, Utter J, Story M, Sockalosky J (August 2002). "Weight control practices and disordered eating behaviors among adolescent females and males with type 1 diabetes: associations with sociodemographics, weight concerns, familial factors, and metabolic outcomes". Diabetes Care. 25 (8): 1289–96. doi:10.2337/diacare.25.8.1289. PMID 12145223.
  2. ^ a b c Alemzadeh R, Ali O (2007). "Section 6: Diabetes Mellitus in Children". In Kliegman RM, Marcdante K, Behrman RE, Jenson HB (eds.). Nelson Textbook of Pediatrics (18th ed.). ISBN 978-1-4160-5622-5.
  3. ^ a b Jones JM, Lawson ML, Daneman D, Olmsted MP, Rodin G (June 2000). "Eating disorders in adolescent females with and without type 1 diabetes: cross sectional study". BMJ. 320 (7249): 1563–6. doi:10.1136/bmj.320.7249.1563. PMC 27398. PMID 10845962.
  4. ^ a b c d Falcão MA, Francisco R (December 2017). "Diabetes, eating disorders and body image in young adults: an exploratory study about "diabulimia"". Eating and Weight Disorders. 22 (4): 675–682. doi:10.1007/s40519-017-0406-9. hdl:10400.14/33260. PMID 28597360. S2CID 11829965.
  5. ^ a b van Heyningen CD, Manoharan KS (2018-12-12). "Diabulimia: an easily missed diagnosis?". British Journal of Diabetes. 18 (4): 167–170. doi:10.15277/bjd.2018.196. ISSN 2397-6241.
  6. ^ a b c d e f g h i j Torjesen I (March 2019). "Diabulimia: the world's most dangerous eating disorder". BMJ. 364: l982. doi:10.1136/bmj.l982. PMID 30824423. S2CID 73478133.
  7. ^ a b c d e f g h Coleman SE, Caswell N (September 2020). "Diabetes and eating disorders: an exploration of 'Diabulimia'". BMC Psychology. 8 (1): 101. doi:10.1186/s40359-020-00468-4. PMC 7513317. PMID 32967730.
  8. ^ Jancin B (September 2008). "Treatment Elusive for Eating Disorders in Type 1" (PDF). www.clinicalendocrinologynews.com. p. 17.
  9. ^ Jancin B (November 2010). "How to distinguish depression and diabulimia". Clinical Psychiatry News. 38 (11): 20. Archived from the original on 2015-06-30.
  10. ^ a b c d e Karidis A (2015-10-28). "When Diabetes Leads to an Eating Disorder". The Atlantic. The Atlantic. Archived from the original on 2015-10-29. Retrieved 2021-05-27.
  11. ^ Hasken J, Kresl L, Nydegger T, Temme M (October 2010). "Diabulimia and the role of school health personnel". The Journal of School Health. 80 (10): 465–9, quiz 514–6. doi:10.1111/j.1746-1561.2010.00529.x. PMID 20840655.
  12. ^ a b Goebel-Fabbri AE, Fikkan J, Franko DL, Pearson K, Anderson BJ, Weinger K (March 2008). "Insulin restriction and associated morbidity and mortality in women with type 1 diabetes". Diabetes Care. 31 (3): 415–9. doi:10.2337/dc07-2026. PMID 18070998.
  13. ^ a b Chelvanayagam S, James J (September 2018). "What is diabulimia and what are the implications for practice?" (PDF). British Journal of Nursing. 27 (17): 980–986. doi:10.12968/bjon.2018.27.17.980. PMID 30235036. S2CID 52307034.
  14. ^ "Recommendations | Eating disorders: recognition and treatment | Guidance | NICE". www.nice.org.uk. Retrieved 2021-05-27.
  15. ^ a b "Diabulimia: 'Diabetes and eating disorder almost killed me'". BBC News. 2020-01-31. Retrieved 2021-05-27.
  16. ^ a b Hastings A, McNamara N, Allan J, Marriott M (December 2016). "The importance of social identities in the management of and recovery from 'Diabulimia': A qualitative exploration". Addictive Behaviors Reports. 4: 78–86. doi:10.1016/j.abrep.2016.10.003. PMC 5836517. PMID 29511728.
  17. ^ Colton PA, Olmsted MP, Daneman D, Farquhar JC, Wong H, Muskat S, Rodin GM (July 2015). "Eating Disorders in Girls and Women With Type 1 Diabetes: A Longitudinal Study of Prevalence, Onset, Remission, and Recurrence". Diabetes Care. 38 (7): 1212–7. doi:10.2337/dc14-2646. PMID 25887359.
  18. ^ Deiana V, Diana E, Pinna F, Atzeni MG, Medda F, Manca D, et al. (March 2016). "Clinical features in insulin-treated diabetes with comorbid diabulimia, disordered eating behaviors and eating disorders". European Psychiatry. 33 (S1): S81. doi:10.1016/j.eurpsy.2016.01.029. ISSN 0924-9338. S2CID 75201343.
  19. ^ Domargård A, Särnblad S, Kroon M, Karlsson I, Skeppner G, Aman J (November 1999). "Increased prevalence of overweight in adolescent girls with type 1 diabetes mellitus". Acta Paediatrica. 88 (11): 1223–8. doi:10.1080/080352599750030329. PMID 10591423.
  20. ^ a b Colton PA, Olmsted MP, Daneman D, Rydall AC, Rodin GM (November 2007). "Five-year prevalence and persistence of disturbed eating behavior and eating disorders in girls with type 1 diabetes". Diabetes Care. 30 (11): 2861–2. doi:10.2337/dc07-1057. PMID 17698613.
  21. ^ Nielsen S (2002). "Eating disorders in females with type 1 diabetes: an update of a meta-analysis". European Eating Disorders Review. 10 (4): 241–254. doi:10.1002/erv.474. Archived from the original on 2013-01-06.
  22. ^ a b "Our position statement on diabulimia". Diabetes UK. Retrieved 2021-05-27.
  23. ^ Richard W (14 January 2019). "King's researchers awarded £1.25 million to design healthcare for potentially fatal eating disorder". www.kcl.ac.uk. Archived from the original on 2020-10-23. Retrieved 2021-05-27.
  24. ^ Ollerenshaw, Tracy (2017-12-22). "Diabulimia documentary had 'massive impact', says charity". BBC News. BBC. Retrieved 2021-06-12.
  25. ^ "Diabulimia: The World's Most Dangerous Eating Disorder". BBC iPlayer. BBC. 24 September 2017. Archived from the original on 2017-09-26. Retrieved 12 June 2021.