Diabulimia

1. Diabulimia AlysiaCariaso, Dinh Ngo, and Tania Cuadra

2. What is Diabulimia?

3. DSM-V: Bulimia NervosaTo be diagnosed a person must display: • Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following: • Eating, in a discrete period of time (ex: within any 2-hr period), an amount of food that is definitely larger than most people would eat during a similar period of time and under similar circumstances. • A sense of lack of control over eating during the episode (ex: a feeling that one cannot stop eating or control what or how much one is eating). • Recurrent inappropriate compensatory behavior in order to prevent weight gain, such as self-induced vomiting, misuse of laxatives, diuretics, or other medications, fasting, or excessive exercise. • The binge eating and inappropriate compensatory behaviors both occur, on average, at least once a week for three months. • Self-evaluation is unduly influenced by body shape and weight. • The disturbance does not occur exclusively during episodes of Anorexia Nervosa.

4. Insulin-Dependent Diabetes:Type 1 and Type 2 • Type 1 diabetes, once known as juvenile onset diabetes, is a chronic condition in which the pancreas produces little or no insulin, a hormone needed to allow sugar (glucose) to enter cells to produce energy. • Type 1 is not preventable, it is in no way the result of a person's lifestyle. • Type 2 diabetes occurs when the body becomes resistant to the effects of insulin or doesn't make enough insulin. • The vast majority of patients who develop Type 2 did so because they were overweight and unfit, and had been overweight and unfit for some time. • Insulin is needed to move blood sugar (glucose) into cellswhere it is stored and later used for energy. Without enough insulin, glucose builds up in the bloodstream instead of going into the cells, and the body is unable to use this glucose for energy.

5. Insulin-Dependent Diabetes:Type 1 and Type 2 • Video: http://youtu.be/4EEtubB74lM?t=37s

6. Diabulimia • Diabulimia is an eating disorder in which people with insulin-dependent diabetes deliberately manipulate their prescribed insulin dose to control weight. When insulin is omitted, calories are “purged” through the loss of glucose in the urine. This “purging” is one of the DSM-V criteria of Bulimia Nervosa. Clinicians have not defined diabulimic insulin omission frequency and duration; however, the proposed definition is as follows: • An insulin reduction at least twice a week or of over one quarter of the prescribed insulin for the purpose of weight loss for more than three months.

7. Etiology • When insulin-dependent diabetes is initially diagnosed, weight loss occurs. However, weight is restored after insulin treatment is routinely applied. • For many girls and women body image is very important. Dissatisfaction of body image occurs very often in diabulimia. • Injecting insulinmay cause bruising, and may be perceived by some as “unattractive.” • Administering a insulin injection, or wearing a insulin pump, causes heightened anxiety for some, especially when in a public setting. • Some may be in denial about their disease. • Complications in the family are often a factor.

8. Diagnosis

9. DSM-V: Other Specified Feeding or Eating Disorder (OSFED) • To be diagnosed as having OSFED a person must present with feeding or eating behaviors that cause clinically significant distress and impairment in areas of functioning, but do not meet the full criteria for any of the other feeding and eating disorders. A diagnosis might then be allocated that specifies a specific reason why the presentation does not meet the specifics of another disorder (ex: Bulimia Nervosa- low frequency). The following are further examples for OSFED: • Atypical Anorexia Nervosa • Bulimia Nervosa (of low frequency and/or limited duration): All of the criteria for Bulimia Nervosa are met, except that the binge eating and inappropriate compensatory behavior occurs at a lower frequency and/or for less than three months. • Purging Disorder: Recurrent purging behavior to influence weight or shape in the absence of binge eating • Night Eating Syndrome

10. DSM-V: Unspecified Feeding or Eating Disorder (UFED) • UFED applies to where behaviors cause clinically significant distress/impairment of functioning, but do not meet the full criteria of any of the Feeding or Eating Disorder criteria. This category may be used by clinicians where a clinician chooses not to specify why criteria are not met, including presentations where there may be insufficient information to make a more specific diagnosis (ex: in emergency room settings).

11. Who’s at Risk of Diabulimia?

12. Who’s at risk of Diabulimia? • Preteen and teenage girls with insulin-dependent diabetes • Generally, this population is preoccupied with appearance, and those with insulin-dependent diabetes tend to have a poorer self-image because of the disease. • Women with insulin-dependent diabetes • On average, about 30% of women who have insulin-dependent diabetes admitted that they have skipped insulin to lose weight. • It’s estimated that 30% to 40% of young girls and women with insulin-dependent diabetes already have developed or will develop an eating disorder at some point in their lives.

13. Warning Signs and Symptoms • Consistent high hemoglobin A1c (glycosylated hemoglobin) or eAG (estimated average glucose). • Frequent ER visits for diabetic ketoacidosis (DKA); however, some diabulimics will skip rapid-acting insulin and continue to take basal insulin; therefore, they may not experience DKA. • Body image concerns (ex: constant weighing and an increased drive for thinness) • Irregular eating patterns (BN) • Discomfort eating around other people • Hoarding food • Irregular or nonexistent menses • Doubtful blood glucose monitoring

14. Complications

15. Complications Poor maintenance of blood glucose for those with insulin-dependent diabetes increases the risk of many complications. Long-term complications develop gradually, and eventually diabetes complications become disabling and/or even life-threatening. Complications include: • Heart and blood vessel disease • Nerve damage (neuropathy) • Kidney damage (nephropathy) • Eye damage • Foot damage • Skin and mouth conditions • Osteoporosis • Pregnancy complications • Hearing problems

16. Complications

17. Proposed Treatment

18. Proposed Treatment • Multi-disciplinary team approach: individuals with diabulimia should be followed by a team of experts. For successful treatment of the multi-faceted symptoms and behavior of diabulimia, a multi-disciplinary team approach is crucial. This team should include:  • an endocrinologist who is sensitive to the psychosocial component of individuals • a psychotherapist experienced with both chronic illness and eating disorders • a registered dietitian who is passionate about eating disorders and, more importantly, skillful in mastering the management of blood glucose patterns and insulin regimens

19. Proposed Treatment

20. Proposed Treatment • Develop healthy eating habitats: Helping individuals to develop healthy eating behavior is the foundation of medical nutrition therapy for diabulimia. • Shift focus away from weight: For those who are obsessed about body weight, refraining from weighing themselves is the best approach. At the Lucille Packard Children's Hospital of Stanford (LPCH) diabetes clinic, patients have the choice of not knowing their weight.  • Find motivators: everyone has something important to them. Success in helping individuals make progress depends on learning what motivates them. • Set small goals: It's overwhelming for those who have diabulimia when healthcare providers or caretakers expect them to accept the full amount of insulin prescribed.

21. Proposed Treatment

22. Overcoming Diabulimia!Video • Overcoming Diabulimia! (Junior Diabetes Research Foundation Video Contest Winner): http://youtu.be/1lAX-pNs0po

23. Treatment Resources Treatment Centers • Center for Hope of the Sierras in Reno, Nevada, special program for diabulima: http://centerforhopeofthesierras.crchealth.com • Laureate Eating Disorders Program in Tulsa, Oklahoma: http://eatingdisorders.laureate.com • Walden Behavioral Care, with multiple locations in Massachusetts: www.waldenbehavioralcare.com • Websites Behavioral Diabetes Institute: http://behavioraldiabetesinstitute.org • Eating Disorder Referral and Information Center: http://edreferral.com • JDRF: www.jdrf.org • Something Fishy: www.something-fishy.org/isf/diabetes.php

24. References

25. References A1c and eAG: American diabetes association. (n.d.). Retrieved from http://www.diabetes.org/living-with-diabetes/treatment-and-care/ blood-glucose-control/a1c/ Casa Palmera Staff. (2012). Diabulimia: a dietetic’s struggle. Casa Palmera, pp. 1-4. Retrieved from www.casapalmera.com/diabulimia-symptoms-and-treatment Criego, A. & Jahraus, J. (2009, November 3). Eating disorders and diabetes. Diabetes Spectrum, 22, Retrieved from http:// spectrum.diabetesjournals.org/content/22/3/135.full.pdf Dada, J. H. (2012, August). Understanding diabulimia- know the signs and symptoms to better counsel female patients. Today’s Dietitian, 14(8), 14. Retrieved from http://www.todaysdietitian.com/newarchives/080112p14.shtml Darbar, N., Mokha, M. (2008). Diabulimia: a body-image disorder in patients with type 1 diabetes mellitus. Human Kinetics, 13 (4), 31-33. Diabulimia. (n.d.). Retrieved from http:// www.nationaleatingdisorders.org/diabulimia-5

26. References Health Nuts Media. (2010). What is diabetes [Web]. Retrieved from http:// www.youtube.com/watch?v=4EEtubB74lM Mathieu, J. (2008). What is diabulimia? Journal of American Dietetic Association, 108 (5), 769-771. Shih, G. (2009, March 3). Diabulimia: What it is and how to treat it. Diabetes Health, Retrieved from http://www.gracenutrition.org/articles/articles.php What is diabulimia?. (n.d.). Retrieved from http://www.wearediabetes.org/diabulimia.php Wilson, E. (2013). Overcoming diabulimia! [Web]. Retrieved from http:// www.youtube.com/watch?v=1lAX-pNs0po

27. Questions • What is diabulimiaand who’s at risk? • List three warning signs/symptoms of diabulimia. • List three complications someone with diabulima may develop.