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Diabulimia – what’s in a name?

25 Jan, 13 | by Dr Dean Jenkins

The charity DWED (Diabetes with Eating Disorders) is “campaigning to have omitting insulin to lose weight officially recognised as a mental illness“.

http://www.bbc.co.uk/newsbeat/20988655

Image of a roseIt is alarming that as many as 30% of adolescent Type 1 females may have altered their insulin doses to lose weight [1]. Reducing insulin causes glucose to rise, many calories are ‘excreted’ in the urine and there is a risk of ketosis and dehydration. In the longer term the poor control increases the risk of microvascular complications of diabetes. Adding binge-eating with vomiting or anorexia to this insulin manipulation makes for a dangerous venture in weight control.

A patient perspective case report [2] gives a good account of how a young person with diabetes started using insulin manipulation and vomiting to control her weight after diagnosis:

“I developed a fear that my weight would continue increasing and never stop. I began cutting back on my insulin to lose a few pounds. When I moved away to college, I started using insulin manipulation again to lose weight. This time, my body was more fragile. One night, I was nauseated, throwing up, and on the verge of diabetic ketoacidosis. I realized I no longer needed to wait until my blood sugar became dangerously high to throw up; I could just make myself do it. It was then that I came to believe that, between insulin manipulation and bulimia, I had found the perfect ‘diet’.”

Giving some ‘condition’ a name is a very useful way of increasing its recognition. The more academic and descriptive ‘disordered eating behaviour in people with type 1 diabetes’ is nowhere near as succinct as the combination of two terms ‘diabetes’ and ‘bulimia’ into a single word ‘diabulimia’. What is in a name? What matters most is what something is, not what it is called.

Is there sufficient reason for labelling this condition as a mental illness? For those that have an eating disorder there is already a classification system and an evidence base for management [3]. I think the additional manipulation of insulin does not necessarily represent another diagnosis; instead, it should be a marker of increased risk and urgency for management under existing guidelines.

 

1. Rydall AC, Rodin GM, Olmsted MP, Devenyi RG, Daneman D. Disordered Eating Behavior and Microvascular Complications in Young Women with Insulin-Dependent Diabetes Mellitus. New England Journal of Medicine 1997;336(26):1849–1854. Available from: http://www.nejm.org/doi/full/10.1056/NEJM199706263362601

2. A battle to overcome ‘diabulimia’. Am Fam Physician 2009 Feb;79(4):263; discussion 263.

3. NICE Eating disorders (CG9): Core interventions in the treatment and management of anorexia nervosa, bulimia nervosa and related eating disorders. 2004. http://www.nice.org.uk/cg009

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  • Guest

    As a Type 1 diabetic I have suffered from diabulimia in the past and I don’t think for one minute it’s a mental issue. I came to the decision to do it to myself following several unsuccessful diets and impatience at trying to lose weight. I believed I suffered from this because I was too lazy to diet properly and I wanted results fast. I soon found, however, that I had diabetic retinopathy (which has now gone) and was constantly feeling nauseous and tired and came to the realisation that I could become blind from this and could even die, and so I stopped. Yes the weight did creep back on but I have lost it again through a sensible diet and exercise.

    I think that to address this issue girls need to be told that this isn’t a long-term weight-loss programme: one can’t be diabulimic forever as you will eventually die and you may lose your sight. Plus, once you begin to give yourself normal amounts of insulin again, the weight will creep back on, even if you are eating a meagre amount of calories.

    In my opinion it can’t be classed in the same category as anorexia or bulimia, which are mental illnesses. I know when I lost over a stone I thought I was slim enough, but those with the conditions above carry on. This needs to be addressed as a diabetes-control condition, rather than mental illness.

  • Guest

    Two of my friends have been in and out of in-patient treatment for diabulimia, and it’s been a lifelong struggle for each of them. IMO there is specific criteria to give it it’s own diagnostic category. I person doesn’t have to binge or restrict food, (s)he can eat normally, omit insulin, and lose weight. How can this not warrant its own classification?

  • Christos Kazazis

    Thanks Dean for bringing this up.It seems that diabulimia is, partly at least, a result of ineffective communication between patients and doctors. And of course the same goes for all diabetic patients where lifestyle modification fails. William Polonsky in DWED webpage provides a very practical guide for professionals in developing such skills. From my point of view caring for diabetes patients in the primary care setting should include an encounter where all the, more familiar to us doctors, aspects will be addressed (physical examination, prescriptions, assessment of lab tests and SMBG diaries) and a seperate encounter a few days apart where a strucured interview, like the one proposed by Dr Polonsky, should be carried out. This should be a systematic approach and not a circumstantial one.

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