Contributor: Margherita Mascolo, MD, Medical Director, ACUTE Center for Eating Disorders at Denver Health
In light of discussions on medical complications of eating disorders, today I wanted to bring attention to diabulimia and its multiple complications.
Diabulimia refers to the co-occurrence of type I diabetes and an eating disorder; it’s the manipulation of life-sustaining insulin in order to lose weight. Before talking about diabulimia, let’s discuss a few basics of diabetes.
What is Diabetes?
Diabetes affects millions of Americans and is largely divided into type I and type II. Approximately 10 percent of patients affected by diabetes have type I (roughly 2 million Americans).
Type I diabetes is an autoimmune disease where the body forms antibodies which attack the cells of the pancreas responsible for the production of insulin. Insulin is a hormone that allows cells of the entire body to take up glucose for ongoing energy needs and metabolism. Without insulin, the body is not able to use glucose as an energy source and essentially becomes starved and breaks down fat and muscle for energy.
Type I diabetes is mainly diagnosed during early puberty, although it may be delayed until the early twenties. Its diagnosis drastically changes patients’ lives as it requires meticulous control of blood glucose (sugar), administration of insulin injections multiple times each day, and control over diet and food intake.
Uncontrolled type I diabetes can lead to multiple complications when the glucose is either low or high as a result of dietary discrepancies or insulin non-compliance.
Dangers of Hypoglycemia and Hyperglycemia
Hypoglycemia, or low glucose, can be caused by not enough ingested calories or too much injected glucose and can quickly lead to arrhythmias, altered mental status, seizures, and death.
Hyperglycemia, or high glucose, can be caused by ingesting too many calories or not injecting enough insulin; it’s not usually deadly immediately but can have devastating long term effects, such as gastroparesis (slow gastric emptying), retinopathy (damage to the retina) leading to blindness, nephropathy (kidney damage) leading to a need for dialysis, strokes, and heart attacks.
In type I diabetics, hyperglycemia can lead to diabetic ketoacidosis where the body is unable to use glucose due to a lack of insulin, breaks down fat and muscle whose byproduct is acid.
This acid is toxic to the body and can cause seizures, coma, and death. Additionally, hyperglycemia due to insulin omission or under-dosing leads to weight loss by several mechanisms.
First of all, high blood glucose leads to glucose being excreted in the urine, which results in calories lost in the urine. Secondly, glucose in the urine pulls water into it, thereby leading to weight loss by dehydration. Lastly, without insulin, the body’s cells are unable to utilize glucose and therefore are in a starved state and utilize other tissues, such as fat and muscle, for energy.
It is therefore extremely important to control diabetes and avoid both hypoglycemia and hyperglycemia; unfortunately, controlling diabetes can unmask an eating disorder given the right genetic and social milieu. Why? Due to the fact that controlling diabetes requires attention to meal planning, reading labels, exercise, and weight control.
Research and Statistics on Diabulimia
Diabetes requires constant focus on numbers: glucose, carbohydrates in meals, and units of insulin, all of which can really feed Obsessive Compulsive Disorder, or OCD, tendencies and increase anxiety.
The statistics of co-occurring type I diabetes and eating disorders are frightening. Eating disorders or disordered eating occurs in as high as 30 percent of patients with type I diabetes. Women with type I diabetes are 2.4 times more likely to develop an eating disorder than their non-diabetic peers. In addition, there are numerous studies that show increased mortality in patients with an eating disorder and type I diabetes.
One study noted that patients with co-occurring type I diabetes and an eating disorder are 3.2 times more likely to die over the 11-year study period, and died on average 13 years before those who didn’t restrict insulin.
In a 10-year study, death rates for anorexia alone were 6.5 percent, for type I diabetes alone were 2 percent, but for anorexia and type I diabetes were 38 percent, meaning that co-occurring type I diabetes and an eating disorder lead to 5 times the mortality rate than diabetes alone.
What can we do to change these statistics on diabulimia? First and foremost is education of the medical community to recognize the prevalence of co-occurring eating disorders in type I diabetics. It’s important for us physicians to screen for covert eating disorders and learn new methods to help our patients manage their diabetes without triggering an eating disorder.
Second of all, it’s important for patients suffering from diabetes and an eating disorder to seek help early and know that there is support for them at all stages of their disease. As with most medical conditions, early recognition and treatment can prevent many devastating consequences.
About the Author: Margherita Mascolo, MD is a Board-Certified Internal Medicine Specialist, Medical Director at ACUTE Center for Eating Disorders and Assistant Professor of Medicine at the University of Colorado.
Dr. Mascolo is the Interim Medical Director of ACUTE Center for Eating Disorder and a hospitalist at Denver Health. She completed her undergraduate work at the University of St. Thomas in Houston, Texas and earned her medical degree at the University of Texas Health Sciences Center. She completed her residency in Internal Medicine at the University of Colorado in Denver. She is board certified in Internal Medicine and is an Assistant Professor in the Department of Medicine at the University of Colorado. Dr. Mascolo is also proud to serve as Medical Liaison Chairperson for the IAEDP Denver Chapter.
References:: National Diabetes Statistics Report, 2014
: Smith FM, Latchford GJ, Hall RM, Dickson RA (2008) Do chronic medical conditions increase the risk of eating disorder? A cross-sectional investigation of eating pathology in adolescent females with scoliosis and diabetes. Journal of Adolescent Health. 42, 1, 58-63.
: Jones JM, Lawson ML, Daneman D, Olmsted MP, Rodin G (2000) Eating disorders in adolescent females with and without type 1 diabetes: cross sectional study. BMJ 2000,320:1563-1566
: Colton P, Olmsted M, Daneman D, Rydall A, Rodin G: Disturbed eating behavior and eating disorders in preteen and early teenage girls with type 1 diabetes: a case-controlled study. Diabetes Care 27:1654-1659, 2004
: Goebel-Fabbri AE, Fikkan J, Franko DL, Pearson K, Anderson BJ, Weinger K. Insulin restriction and associated morbidity and mortality in women with type 1 diabetes. Diabetes Care. 2008 Mar;31(3):415-9
: Nielson S, Emborg C, Molbak AG: Mortality in concurrent type 1 diabetes and anorexia nervosa. Diabetes Care 2002; 25:309–212
The opinions and views of our guest contributors are shared to provide a broad perspective of eating disorders. These are not necessarily the views of Eating Disorder Hope, but an effort to offer discussion of various issues by different concerned individuals.
We at Eating Disorder Hope understand that eating disorders result from a combination of environmental and genetic factors. If you or a loved one are suffering from an eating disorder, please know that there is hope for you, and seek immediate professional help.
Published on June 18, 2017.
Reviewed By: Jacquelyn Ekern, MS, LPC on June 18, 2017.
Published on EatingDisorderHope.com