Diabulimia

Editor(s)-in-Chief: C. Michael Gibson, M.S.,M.D. [mailto:mgibson@perfuse.org] Phone:617-632-7753; Mark Warren, M.D., M.P.H.; Fellow, Academy of Eating Disorders [mailto:mwarren@eatingdisorderscleveland.org]

Overview
Diabulimia (a portmanteau of diabetes and bulimia) refers to people with Type 1 diabetes who omit their insulin injections for the purpose of weight loss. Without the insulin injections, blood sugar levels rise as the cells cannot take in glucose. The body, in an attempt to lower the blood sugar, spills excess glucose into the urine.

Prior to a diagnosis of Type 1 diabetes there is a weight loss but, upon diagnosis, a person with Type 1 diabetes is put on insulin injections, a more controlled diet, and several blood sugar checks a day. The weight that was lost is quickly gained back. However, someone who realizes that omitting or severely reducing insulin dosages leads to weight loss may be tempted to do so, especially if the individual believes they are overweight. Omitting insulin injections does have the effect of losing weight, even though appetite and thirst increase, as well as urine volume.

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 and/or compulsive eating. In cases where a person with Type 1 diabetes has another eating disorder, there is a tendency to discuss the other eating disorders more openly than they do about diabulimia as many people with diabetes are not happy that they have lost control of their diabetes. These individuals are often not aware that diabulimia is more common than what they think and is also very difficult to overcome. Unlike anorexia and bulimia, diabulimia only sometimes requires the afflicted individual to stop caring for a medical condition. Unlike vomiting or starving, there is sometimes no action or willpower involved. Diabulimia may be more appealing to individuals who want to lose weight and do not want to feel hungry, or to not engage in vomiting in order to purge. Often there is an obsessive compulsive urge to engage in this activity for the purpose of emotional disassociation or a need to satisfy feelings of 'control'.

This condition can be triggered or exacerbated by the need for constant vigilance in regard to food, weight and glycemic control. In adolescents "the need for parental control over the young Diabetic's life, and the increased weight gain that insulin treatment can cause, may all play roles in the increased risk for onset of Anorexia and/or Bulimia." (Something Fishy website) The frustration of hard to control blood sugars and their subsequent effects on weight and self perception (altered by dealing with a chronic illness) can also be damaging to self esteem and body image.

A person with diabulimia, especially if not caught and treated early, is likely to suffer the extent of diabetes earlier than a person with diabetes who is maintaining their diabetes in a healthy manner. The extent of diabetes include renal failure, blindness and diabetic neuropathy. With diabulimia there is an increased chance of fatality. Diabetic ketoacidosis (DKA) is very common in persons with Type 1 diabetes that have diabulimia. This is due to the reduction in the amount of insulin and an increase in blood sugars levels. DKA is a very serious condition that occurs without enough insulin and without treatment causes death.

Most commonly Diabulimia appears to start in adolescence and is more likely to occur in women than men. Diabulimia can be identified in a patient if there are unexplainable spikes in their Hemaglobin A1c, weight loss, lack of marks from finger sticks, lack of prescription refills for diabetes medications, and records that do not match the HbA1c.

Symptoms

 * Note: these are the symptoms that are present with uncontrolled diabetes

Short term
These are the short term symptoms of patients with diabulimia
 * Constant urination
 * Constant thirst
 * Excessive appetite
 * High blood glucose levels (often over 600)
 * Weakness
 * Fatigue
 * Large amounts of glucose in the urine
 * Inability to concentrate
 * Electrolyte disturbance
 * Severe ketonuria, and, in DKA, severe ketonemia
 * Low sodium levels

Medium term
These are the medium term symptoms of patients with diabulimia. They are prevalent when diabulimia has not been treated and hence also includes the short term symptoms
 * Muscle atrophy
 * GERD
 * Indigestion
 * Severe weight loss
 * Proteinuria
 * Moderate to severe dehydration
 * Edema with fluid replacement
 * High cholesterol
 * Death

Long term
If a person with Type 1 diabetes with diabulimia is still alive after a medium term - which is usually due to phases where insulin is injected and phases of diabulimia (also known as a relapse) - then the following symptoms can also be expected:
 * Severe kidney damage
 * Blindness
 * Severe neuropathy
 * Extreme fatigue
 * Edema (during blood sugars controlled phases)
 * Heart problems
 * High cholesterol
 * Osteoporosis