Diabulimia: Comorbid Type 1 Diabetes and Eating Disorders

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Diabulimia is the intentional misuse of insulin by patients to control their weight.
Diabulimia is the intentional misuse of insulin by patients to control their weight.

Dual diagnosis of an eating disorder and diabetes mellitus type 1 (ED-DMT1) is a somewhat newly recognized psychiatric illness in which patients with type 1 diabetes intentionally misuse insulin for weight control. The seriousness of the condition was addressed at the recent Diabetes UK Professional Conference, held in Manchester, March 8-10, 2017.

What Is ED-DMT1?

The diagnosis of ED-DMT1 refers to an intentional misuse of insulin by patients diagnosed with type 1 diabetes as a means of losing weight. By diminishing or entirely omitting regular doses of insulin, patients can trigger hyperglycemia (high blood glucose levels) and subsequent glucose excretion in the urine, resulting in weight loss. Although this condition is often referred to as "diabulimia," a combination of the words diabetes and bulimia, it may or may not be associated with bulimia or any of its symptoms.1

"Patients can be diagnosed with any of the [Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition] eating disorders, including anorexia nervosa, bulimia nervosa, binge eating disorder, or other specified feeding or eating disorder," said Marcia Meier, diabetes educator, and Heather Gallivan, clinical director at the Melrose Center, which specializes in recovery from eating disorders, in an interview with Psychiatry Advisor.. Individuals with ED-DMT1 may even eat normally, but subsequently control their insulin intake to achieve weight loss.2

This condition often leads to serious complications and is associated with a higher mortality rate than among people with diabetes who do not also have an eating disorder. Therefore, early detection of its signs and symptoms is critical. Some of these signs include:3,4

Physical Signs

  • Regularly occurring diabetic ketoacidosis (lack of insulin in the body)
  • Frequent hypoglycemia
  • Irregular menstrual periods and delayed puberty
  • High hemoglobin A1c levels
  • Recurrent clinical visits for low blood sugar control
  • Anemia

Behavioral Signs

  • Binge-eating (without weight gain)
  • Loss of appetite
  • Anxiety over weight or body appearance
  • Injecting insulin only in private
  • Missing diabetes-related health checks
  • Extreme attention to details around food intake

The Psychological Aspects of ED-DMT1

Depressive symptoms in individuals with type 1 diabetes are associated with an increased risk of developing comorbid eating disorders.5 It is the discipline around food intake monitoring and weight management demanded from those with type 1 diabetes that may contribute to the progression of eating disorders. Certain avoidant coping methods, such as self-blame and wishful thinking, have also been identified as characteristic of adolescents with both an eating disorder and type 1 diabetes. 6

Meier and Gallivan note that untreated depression and anxiety in patients can prolong treatment; although the first step is to treat any diabetes-related health complications and bring the individual's insulin use, blood glucose levels, weight, and food intake back to normal levels, the next stage involves working with the patient to address any psychiatric conditions.7

Notably, higher therapy dropout rates have been identified among patients with ED-DMT1 compared with those with eating disorders but not diabetes. Patients with diabetes are hyperaware of the risks that stem from insulin manipulation, which complicates the problem, underlines the importance of going beyond merely educating patients about insulin management, and also places emphasis on addressing underlying emotional factors.8

A Multidisciplinary Approach to Treatment

Since 2005, the Melrose Center, which has locations throughout Minnesota, has worked with both the International Diabetes Center and the Adult and Pediatric Endocrinology group of Park Nicollet Health Services to develop a holistic recovery program for patients with ED-DMT1. Having treated more than 350 patients with this program, Meier and Gallivan believe "treatment should be with a multidisciplinary team including a psychologist or therapist familiar with diabetes, a registered dietician who also has training or knowledge in diabetes, a certified diabetes educator, a primary care provider, an endocrinologist, and a psychiatrist, as comorbid psychiatric diagnoses are very common with patients who have both an eating disorder and diabetes. If left untreated, these other mental health conditions can complicate treatment of the eating disorder." 

"A multidisciplinary team is critical due to the physiological and psychological nature of this illness," the duo expands. "All members of the treatment team must have knowledge about both illnesses. Trusting, non-critical relationships are vital to recovery. Many of these patients have seen providers who use scare tactics (such as the threat of complications from diabetes) and come to treatment feeling great shame and guilt about what they have been doing to their bodies when they don't take care of type 1 diabetes." They cite cognitive behavioral therapy, dialectical behavior therapy, and if the patient is an adolescent, family-based therapy as effective options in treating the eating disorder and the diabetes.9,10

Although a multidisciplinary approach has shown promise, limited evidence remains in terms of efficacy. In addition, specific behaviors associated with ED-DMT1 need to be examined in more depth, including insulin manipulation, which is dangerous, potentially fatal, and unique to diabetes.11

In addition, further research is also needed to better understand the interaction between diabetes and eating disorders. It is clear, as stated by Meier and Gallivan, that establishing a trustful relationship with therapists and physicians may be just as critical for treatment as regulating insulin and food intake. It has been proposed that eating disorders among people with type 1 diabetes may need to have a unique category of diagnoses, as unless the underlying diabetes-specific aspects of eating disorder development are addressed, the problem can't be sufficiently treated. Ignoring the psychological factors and focusing solely on the medical aspects may prove harmful to patients with this disorder.13 Adequate education of those healthcare professionals treating this growing problem, including psychiatrists, is necessary to foster better prognosis.

References

  1. Eating Disorders Catalogue (2015) The dual diagnosis of an eating disorder and type 1 diabetes mellitus. http://www.edcatalogue.com/dual-diagnosis-eating-disorder-type-1-diabetes-mellitus/. Published February 2, 2015. Accessed April 7, 2017.
  2. Berg, B. Eating disorders and type 1 diabetes – Dr. Ovidio Bermudez. https://www.eatingrecoverycenter.com/blog/2016/03/21/eating-disorders-and-type-1-diabetes-dr-ovidio-bermudez. Published March 21, 2016. Accessed April 7, 2017.
  3. We Are Diabetes. What is diabulimia? http://www.wearediabetes.org/diabulimia.php. Accessed April 7, 2017.
  4. Conason, A. Diabulimia: when diabetes and eating disorders collide. https://www.psychologytoday.com/blog/eating-mindfully/201502/diabulimia. Published February 6, 2015. Accessed April 7, 2017.
  5. Diabetics With Eating Disorders. Signs and symptoms of ED-DMT1/diabulimia. Accessed April 7, 2017.
  6. Gagnon C, Aimé A, Bélanger C. Predictors of comorbid eating disorders and diabetes in people with type 1 and type 2 diabetes [published online September 7, 2016]. Can J Diabetes. doi: 10.1016/j.jcjd.2016.06.005
  7. Grylli V, Wagner G, Hafferl-Gattermayer A, Schober E, Karwautz A. Disturbed eating attitudes, coping styles, and subjective quality of life in adolescents with type 1 diabetes. J Psychosom Res. 2005;59(2):65-72.
  8. Bermudez, O., & Sommer, J. (2012). T1D intel: learning about the dual diagnosis of an eating disorder and type 1 diabetes. http://www.jdrf.org/blog/2012/10/15/t1d-intel-learning-about-the-dual-diagnosis-of-an-eating-disorder-and-type-1-diabetes/. Published October 15, 2012. Accessed April 7, 2017.
  9. Custal N, Arcelus J, Agüera Z, et al. Treatment outcome of patients with comorbid type 1 diabetes and eating disorders [published online May 16, 2014]. BMC Psychiatry. doi: 10.1186/1471-244X-14-140
  10. Eating Disorder Therapy LA. AED tweetchat on diabulimia. https://www.eatingdisordertherapyla.com/aed-tweetchat-on-diabulimia/. Published June 6, 2014. Accessed April 7, 2017.
  11. Le Grange D, Lock J, Agras WS, Bryson SW, Jo B. Randomized clinical trial of family-based treatment and cognitive-behavioral therapy for adolescent bulimia nervosa. J Am Acad Child Adolesc Psychiatry. 2015;54(11):886-894. doi: 10.1016/j.jaac.2015.08.008
  12. Joslin Diabetes Center. Restricting insulin doses increases mortality risk in women with type 1 diabetes, study suggestsScienceDaily. http://www.sciencedaily.com/releases/2008/02/080227082849.htm. Published February 28, 2008. Accessed March 31, 2017.
  13. Dada, J. Understanding diabulimia - know the signs and symptoms to better counsel female patients. Today's Dietitian. 2012;14(8):14.
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