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What is the Relationship between Eating Disorders and Type 1 Diabetes?

Zoe Nagel

May 2, 2009

http://rds.yahoo.com/_ylt=A9G_bF905fdJHIIA6LijzbkF/SIG=12n2bnlda/EXP=1241069300/**http%3A/www.self.com/images/livingwell/2007/10/liar03_diabulimia.jpg

http://www.self.com/images/livingwell/2007/10/liar03_diabulimia.jpg

Introduction:

            Though not classified as an official type of eating disorder in the DSM-IV, “diabulimia,” or skipping an insulin shot on purpose in order to lose weight, has become a serious issue.  As of now, “diabetes is the fifth-deadliest disease in the United States, and it has no cure” (http://www.diabetes.org/type-1-diabetes.jsp).  Despite these facts, women continue to add to the risk and complications by refusing to take their insulin shots.  This paper will go over what is type 1 diabetes and how detrimental an eating disorder in addition to diabetes could be. 

 

What is Type 1 Diabetes?:

          Type 1 diabetes is classified as the body being unable to create insulin (http://www.diabetes.org/type-1-diabetes.jsp).  Insulin is a hormone produced by the pancreas that is essential to breaking down glucose (sugar), starch, and other foods into energy.  In order for the body to be able to imitate this natural process, insulin is injected into the skin using a shot so that it can enter the bloodstream.  Nowadays, there are a wide variety of types of insulin available and over 20 types are sold in the US.  The insulin is either made in a lab or taken from pigs as their circulatory and endocrine systems are similar to our own. 

            There are many complications that can come from type 1 such as blindness, kidney failure, heart disease, nerve damage, and more. 

Dangers of Diabulimia:

            The major risk associated with diabulimia is diabetic ketoacidosis or DKA (http://www.diabetes.org/type-1-diabetes/ketoacidosis.jsp).  DKA can lead to diabetic coma or even more fatal, death.  DKA is characterized by a buildup of ketones in the body and literally is the breakdown of fat in a desperate attempt to provide the body with energy.  Ketones are acids that accumulate in the blood and can then poison the body, with the ability to reach every organ because they are conveniently located in the bloodstream.  Ketones show up in urine when one’s body is low on insulin and thus serves as an indicator that the body is going to go into failure.  Getting DKA is a slow process in itself, but once vomiting occurs, DKA can become terminal in a few hours. 

            In the short term, restricting insulin causes higher than normal blood sugar levels, causing the insulin manipulator to feel dehydrated, fatigued, and to suffer from a muscle tissue deterioration (http://www.medicinenet.com/script/main/art.asp?articlekey=81960).  In the long term, the dangers are as listed above as the complications of type 1 diabetes: kidney failure, eye disease, and vascular disease which could even result in amputation in a worst-case scenario.  Though most endocrinologists and other professionals in the fields know of diabulimia, many family members and primary care givers do not. 

Diabulimia in the Media:

http://www.jillianhessel.com/presspics/covers_big/200511_fitness.jpg

Bergen (2007) writes in the popular health magazine Self about diabulimia and how it’s affecting more and more young girls.  Upon developing the disease, a woman will experience weight loss as the body fails to take in glucose and other products that contribute to weight gain.  When they are diagnosed and begin taking insulin, they retain a lot of water weight and salt at first and can easily put on 10-15 pounds in a week.  Often times young girls are diagnosed right before puberty kicks in, which means that in addition to the initial weight gain, they will also have to deal with their soon-to-be curvy figure.  This change causes a fear of weight gain and thus a fear of the insulin shots.  One girl in the article even refers to them as “fat shots.”  This loss of control thus contributes to the start of diabulimia, which enables the person to eat as much as they want with no fear of gaining weight, as the body cannot process the foods.  By purposely not taking their insulin shots, they are able to regain the feel of control that they lost after they disease developed and creating a form of purging, similar to in bulimia cases.  Also, the media is an incessant influence on society and in particularly young women who are already prone to the peer pressures to fit in. 

The real problem comes into play when treatment is needed.  Most clinicians are not capable of handling this “dual diagnosis” and there is a severe lack of treatment centers, as the disease is still not well-known or fully recognized.  However, Walker, a diabetes specialist in Scotland, performed a study on 14 women with type 1 diabetes and eating disorders.  The results were devastating as “after 12 years, five of the women had died, two were blind and three were on kidney dialysis or had received a kidney transplant. The youngest of the women who had died was only 25; the oldest 42” (4).  The irony lies in the fact that before 1922, insulin shots had not been discovered and thus a diagnosis of diabetes was equivalent to a diagnosis of death.  Even 85 years after this breakthrough, girls are still opting for this “death sentence.”

In a newsfeed by Gardner (2009) for ABC, she brings up many statistics relating to eating disorders and diabetes to present to the public.  Some of these statistics include how women who take less insulin than recommended are three times more likely to die and how women diagnosed with type 1 diabetes are 2.5 times more likely to form an eating disorder than women who do not have diabetes.  Only half of adult women with diabetes maintain the correct glucose levels.  Although solutions to this swiftly growing problem are not necessarily clear, the end of the article suggest that upon diagnosis, women should be screened for an eating disorder, as the two correlate quite highly as the statistics demonstrate. 

Research:

            Although the field of diabulimia has much left to be explored and discovered, endocrinologists and other specialists have known about the problem for decades.  Research has only gotten better in the current years and three particular case studies will be discussed, though of course there are many more that have been and will be done in the future. 

Case 1:

            In a case report done by Mannucci et al (1995), the scientists studied one individual type 1 diabetic woman who started suffering from binge eating disorder after she was diagnosed.  The woman would wake up in the middle of the night and binge on large amounts of food, in part because of high hypoglycemic episodes, where the blood sugar content is low and needs to be refueled.  The patient also was discovered to have dysthymia in therapy, which her mother had been suffering from for around three years.  To treat the hypoglycemia, the patient’s insulin doses were changed, but the binge eating continued.  When self-tested upon awaking before the changes, the patient did suffer from hypoglycemia while after the changes, there were nights where she did not.  The woman did not think she was overweight and did not say she restricted her insulin, but she was deathly afraid of gaining weight. 

            The researchers concluded that there was not enough data to show a high comorbidity between late night hypoglycemic episodes and binge eating disorder.  The researchers suggest further studies in this area.  The prognosis in this case was correct in that one case study that was not even very conclusive cannot summarize cases on a global scale.  It is, however, interesting that the patient developed binge eating disorder because usually a fear of gaining weight would lead to a disorder like anorexia or bulimia.  This fact could mean that glucose levels did contribute, but does not explain why the binge eating continued after the glucose levels were leveled out.  The case, though detailed enough, was somewhat subjective as they relied on the patient’s self-testing and answers from surveys and therapy sessions to draw results.  The report itself did not include very much objective evidence, especially statistic-speaking.  The study would prove more useful if done on a larger scale and with more objective values. 

Case 2:

            In a one-year study done by Raingeard et al (2004), 10 patients with type 1 diabetes and either bulimia or binge eating disorder were taken in for the experiment.  All of the patients had not responded to any sort of antidepressant drug or therapy.  The average age of the patients was 22 and the average range of years having type 1 diabetes was 8 years.  The starting BMI (body mass index) of the 10 patients was 25.  All patients received the drug naltrexone, a drug that “is currently used to help weaning off alcohol, opiates, or heroin.”  Other recent studies also show significant improvements using naltrexone to treat bulimic patients. 

            Weekly binge-eating episodes were reduced drastically within the first two months and continued to stay decreased by 86% at the end of one year.  Weekly bulimic episodes were initially decreased by 50% after the first two months and after a year by 64%.  On questionnaires, there was significant improvement in the “attitude toward impulsiveness” section as well as the “low self-esteem” section (p<.01 and p<.05 respectively, meaning the attitude toward impulsiveness improved slightly more than the low self-esteem issues). 

            The fact that there was a lack of a control group, aka a placebo group who did not receive the drug, in the trial seems to make the trial less noteworthy.  Although the improvement did seem drastic, rapid, and continuous with the many number given, there really needs to be more extensive research done on the drug before a direct correlation is provided. 

Case 3:

            In a study performed by Takii et al (2002), the researchers gathered 79 women with type 1 diabetes along with either bulimia nervosa or binge eating disorder to experiment with.  The researchers felt that the different subgroups of bulimia nervosa along with the diabetes could be classified as almost separate entities, and the binge eating disorder group was to be used as a comparison group.  The women were thus separated by the way they purge as follows: group BN-1 had 22 participants and was the group where only severe insulin reduction was used as a purge; group BN-IP had 22 participants and was the group characterized by purges of both insulin omission and vomiting and/or laxative abuse; group BN-NI had 11 participants and was the group with no insulin omission but instead some other form of purging; group BED had 24 participants and as said before, served as a group to compare the results from the bulimic groups to.  The purpose of the experiment was to first, learn more about patients with type 1 diabetes and some form of bulimia nervosa and second, to prove that the researchers’ two hypotheses were correct: that the BN groups would have more severe medical problems than the BED group and that it is possible and beneficial to divided the BN groups by their type of purging, as the different purges show different clinical results.

            The results showed that the BN-IP and BN-I groups had the highest hemoglobin levels, which makes sense considering these were the two groups in which insulin was not used in the correct amount.  Also, the BN-IP group had the highest rates of organ failures such as kidney or eye damage, again very plausible because the severe omission of insulin is being mixed with another form of purging which also has detrimental effects on the body.  Similarly, the BN-IP group also had the highest rates of patients suffering from DKA.  The BN-NI group had the highest scores relating to psychological issues related to eating like depression and anxiety.  The researchers concluded that their hypotheses were right as each subgroup had different and unique results and each were more severe than the BED group.

            This experiment seemed very well-organized and objective, as the researchers only interfered with the patients’ lives in order to test for psychological issues and to record their different medical issues.  Otherwise, the experiment was really about the researchers watching women with type 1 diabetes and bulimia nervosa and learning.  The experiment proved that there might need to be separate treatment based on the different purging types for women suffering from dual diagnosis.  The researchers also used an interesting way to decide if a patient classified as diabulimic: if a patient skipped or omitted more than one-fourth of her prescribed insulin, she was marked as diabulimic.  One of the current issues is that diabulimia on its own is not an eating disorder by DSM-IV standards, but maybe using this as one of the marks for having diabulimia can help make this eating disorder into a reality in the DSM-IV. 

What Can Food and Nutrition Professionals Do to Help?

http://www.medicinenet.com/diabetes_foot_problems_pictures_slideshow/article.htm

            This question posed and answered by Mathieu (2008) is becoming more and more commonly asked.  In general, it seems evident that professionals need to be better educated, as diabulimia is not known worldwide.  Also, for any eating disorder, professionals should constantly be looking for telltale signs that could help lead to early eating disorder identification.  Facilities for patients with eating disorders also ought to become better equipped to handle diabetic patients, as many are currently not.  Goebel-Fabbri, a renowned researcher in the field of eating disorders and diabetes, concludes that professionals should stop dealing with diabetic patients in such a limitary fashion.  Patients should not be told what they can and cannot eat, but instead given the methodology to be able to cope with living a normal life.  The former concept works to enforce the eating disorder mentality. 

What’s Being Done Then?

            At a recent conference at Park Nicollet (2008), experts in the areas of diabetes and eating disorders met to discuss the plans for the combination of the two issues, or dual diagnosis as previously stated.  The purpose of the meeting is to “raise awareness, collect current best practices, define research questions and submit a peer reviewed paper to a major medical journal critically reviewing this field. They also hope to identify international centers for treatment and establish an ongoing collaborative network.”  One of the major concerns is the lack of treatment and treatment facilities available.  As of now, diabulimic patients who seek treatment jump between specialists for the two areas and the two specialists often do not partner together.  The conference hopes to enable the specialist to create a unified force to deal with the disease.  As Dr. Jahraus correctly puts it, “It [the treatment plans] just can’t wait any longer.”

What Should and Needs to be Done:

            In response to the question posed at the beginning of this paper, there seems to be a strong correlation between eating disorders and type 1 diabetes predominantly for diagnosed pre-teens and teens.  This correlation is only strengthening as more and more people find out that skipping out on insulin doses has this effect on people: the effect of being able to eat as much as possible without gaining weight.  Even if one does not have an eating disorder, learning that this is a possibility is a hard thing to ignore every once and a while.  Everyone wants to feel like they can have control. 

            The research on diabulimia seems to be well on its way, as just last year the conference of professionals was held at Park Nicollet.  This conference in addition to the numerous amounts of case studies being performed proves that people are starting to take diabulimia seriously and consider it as its own, distinctive eating disorder.  It’s only an amount of time before the DSM-IV coins the term and makes the problem official.  What needs to be done is what is already on its way to being done: educating people (not only type 1 diabetics) on the risks of the disease.  Facilities also need to start becoming better equipped to handle diabetic patients, or there should be more facilities built to handle diabulimic patients.  But before this can be done, there needs to be a set of universal guidelines in how to best treat diabulimia, as going to an endocrinologist and then a therapist for eating disorders often have different methodologies.  Setting these guidelines was the purpose of the conference though, so all that needs to be done is to put the guidelines set by the professionals at the conference into writing.  Diabulimia is not going to stop spreading and growing larger, and so we must fight fire with fire and be prepared to treat and prevent it. 

Sources Cited:

Bergen, J (2007, November). Diabulimia. Self.

Gardner, A. (2009, February 27). 'Diabulimia' triples risk of death among women with diabetes. HealthDayNews.

Ketoacidosis. Retrieved April 21, 2009, from American Diabetes Association Web site: http://www.diabetes.org/type-1-diabetes/ketoacidosis.jsp.

Mannucci, E., Ricca, V., & Rotella, C. M. (1995). Clinical features of binge eating disorder in type 1 diabetes: a case report. International Journal of Eating Disorders. 21, 99-102.

Mathieu, J. (2008).What is diabulimia?. Journal of the American Dietetic Association. 108, 769-70.

Mathur, R. (2008, February 22). Diabulimia-eating disorders. Retrieved April 28, 2009, from MedicineNet.com Web site: http://www.medicinenet.com/script/main/art.asp?articlekey=81960.

Park Nicollet hosts conference to explore the best treatment of 'Diabulimia'. (2008, September). Canada NewsWire.

Raingeard, I., Courtet, P., Renard, E., & Bringer, J. (2004). Naltrexone improves blood glucose control in type 1 diabetic women with severe and chronic eating disorders. Diabetes Care, 27, 847.

Takii, M., Uchigata, Y., Nozaki, T., & Nishikata, H. (2002). Classification of type 1 diabetic females with bulimia nervosa into subgroups according to purging behavior. Diabetes Care, 25, 1571-5.

Type 1 Diabetes. Retrieved April 21, 2009, from American Diabetes Association Web site: http://www.diabetes.org/type-1-diabetes.jsp.

 

 

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