April 25, 2016

Diabulimia: Q&A with Dr. Ovidio Bermudez

Dr. Ovidio Bermudez | Chief Clinical Officer and Medical Director of Child and Adolescent ServicesWhat is diabulimia?

Diabulimia, also known as ED-DMT1 in healthcare circles, describes the intentional misuse of insulin for weight control—this could include decreasing the prescribed dose of insulin, omitting insulin entirely, delaying the appropriate dose or manipulating the insulin itself to render it inactive. Manipulating insulin in any of these ways can result in hyperglycemia (high blood glucose levels) and glucose excretion in the urine, which causes weight loss. This is where the term “diabulimia” comes from—in a sense, calories are “purged” from the body in this way. This term is slightly confusing, as a person suffering from diabulimia may be suffering from any eating disorder, not exclusively bulimia nervosa. They may exhibit any number of eating disorder behaviors, or they may only manipulate their insulin and otherwise have normal eating patterns.

How common is the dual diagnosis of an eating disorder and type 1 diabetes?

The scientific literature reveals that having type 1 diabetes puts an individual at increased risk for developing an eating disorder or disordered eating.[1] One study found that as many as 35 percent of young adult women with type 1 diabetes met the criteria for a “sub-threshold” eating disorder (display symptoms of an eating disorder but do not meet the full diagnostic criteria) and as many as 11 percent  met the criteria for a full-syndrome eating disorder.[2] These figures are distressing when compared to the incidence of eating disorders among women in general, in which an estimated 0.5 to 3.7 percent of women suffer from anorexia nervosa and an estimated 1.1 to 4.2 percent of women have bulimia nervosa in their lifetime.[3]

Why is the risk of eating disorders higher among type 1 diabetics?

Several factors contribute to this heightened risk, foremost among them is a necessary emphasis on food and dietary restraint to effectively manage type 1 diabetes, including carbohydrate counting and meal planning. For some, this can result in an unhealthy focus on food, numbers and control. Weight gain often accompanies the initiation of insulin treatment, which can be both physically and emotionally uncomfortable, and although dangerous, insulin manipulation is an easy and effective method of weight loss. Additionally, the standard psychological effects of having to manage a chronic medical condition such as type 1 diabetes can contribute to ED-DMT1—depression and anxiety are common comorbidities with both type 1 diabetes and an eating disorder diagnosis.

What are the warning signs of diabulimia?

Some or all of the following warning signs may occur if an individual with type 1 diabetes has a co-occurring eating disorder:

  • Poor blood-glucose control (especially if the individual has had good control previously)
  • Hyperglycemia
  • Recurrent or persistent ketonuria
  • Recurrent episodes of diabetic ketoacidosis (DKA); symptoms include polydipsia (excessive thirst), polyuria (frequent urination) and/or polyphagia (increased hunger)
  • Severe recurrent episodes of hypoglycemia
  • Higher than usual hemoglobin A1c levels (despite normal blood sugar records; which may be falsified by the individual)
  • Microvascular disease affecting the eyes, kidneys and heart
  • Peripheral neuropathy

In addition to these warning signs specific to diabetic patients, general signs of disordered eating should be a red flag for loved ones and healthcare providers.  Dieting, binge eating, secrecy or abnormal behaviors or rituals around food, eating and insulin administration, obsession with body weight, size or shape, negative body image, excessive exercise, depressed mood, social withdrawal, deterioration of school or work performance are all common signs of an eating disorder.

What are the health risks of diabulimia?

I have observed an interesting dichotomy—while most people with type 1 diabetes are very familiar with the complications that can arise from their illness, they generally lack awareness of the serious complications that can arise as a result of the dual diagnosis of ED-DMT1. Additionally, many healthcare providers and diabetes specialists aren’t aware of the increased incidence of eating disorders in this patient population or the seriousness of complications of diabulimia. In a nutshell, the hyperglycemia (elevated levels of glucose in the bloodstream) caused by deliberate insulin manipulation leads to damage of small vessels (microvascular damage) and nerve cells, specifically peripheral nerves.  In the dual diagnosis of ED-DMT1, the degree of hyperglycemia is so significant that the microvascular disease and peripheral nerve damage is greatly accelerated and more severe. Other common complications frequently seen in all types of diabetes are also accelerated in ED-DMT1, including damage to the retina of the eye, kidneys heart (related to microvascular disease) and small nerve damage (peripheral neuropathy, which can manifest with pain, tingling, and numbness of hands and feet). Perhaps the most important concern for ED-DMT1 patients is a significantly increased mortality risk. In one study, the risk of death for ED-DMT1 was 17-fold compared to type 1 diabetes alone and seven-fold compared to anorexia nervosa alone.[4]

How is diabulimia treated?

The complications and increased mortality rate associated with ED-DMT1 underscores the importance of an informed, collaborative treatment approach that acknowledges and addresses both illnesses. The most important predictors of successful treatment are early recognition and intervention by a multidisciplinary treatment team consisting of a medical doctor, therapist and/or psychiatrist, and Registered Dietitian (it is preferable that all providers have expertise in the care of this dual diagnosis).  At ERC, the initial goal of treatment for diabulimia is to normalize the use of insulin, blood glucose levels and patient weight, and avoid acute and chronic complications of insulin deficiency and hyperglycemia. Medical stabilization, which can sometimes require hospitalization at the Inpatient level of care, is followed by interruption of eating disorder behaviors, a thorough exploration of the function the eating disorder serves in the patient’s life, as well as building skills to help patients healthfully manage stress and anxiety in the future.

In addition to delivering informed, multidisciplinary treatment for diabulimia, ERC is committed to fostering improved understanding of this condition among healthcare professionals working with diabetic patients.  Professional education explores the heightened risk factors for the development of an eating disorder, health risks associated with insulin manipulation and the process for referring patients to a higher level of care when necessary to address patients’ unique recovery needs.

Ovidio Bermudez, MD, FAAP, FSAHM, FAED, CEDS, Fiaedp, Chief Clinical Officer and Medical Director of Child and Adolescent Services at Eating Recovery Center, shares expert insights about diabulimia, a pattern of disordered eating in which a diabetic individual manipulates their insulin as a weight management tool.  Also known as the dual diagnosis of an eating disorder and type 1 diabetes (ED-DMT1), Dr. Bermudez is an internationally recognized thought leader in the recognition and treatment of this condition, speaking on the topic regularly to both professional and lay audiences alike.

[1] http://care.diabetesjournals.org/content/38/7/1212

[2]http://care.diabetesjournals.org/content/15/10/1356.abstract?ijkey=cfb729fa64726a3f59924bd2e7351ae98184dc4b&keytype2=tf_ipsecsha

[3] http://www.nimh.nih.gov/publicat/nedspdisorder.cfm

[4] Mortality in concurrent type 1 diabetes and anorexia nervosa. Nielsen S, Emborg C, Mølbak AG. Diabetes Care. 2002 Feb; 25(2):309-12.

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