Adolescence and young adulthood is fraught with many obstacles and barriers to the smooth passage towards maturity and entrance into the adult world. Even without the additional burden of chronic illness, our emerging high school, college, and graduate school scholars endure multiple stressors. Eating disorders have been prevalent throughout history; however, increased attention to its etiology and treatment began during the early 1970s and now is considered a major psychological disorder with severe medical ramifications. Indeed, many of us who attended university in the 1970s were very much aware that several of our peers seemed to have issues with food that included forced vomiting, binging, and at times, starvation. I am still troubled, even to this day, that as a college student, having observed the cyclical nature of this disorder in a close friend and totally ignorant of the medical and psychological consequences, I did not insist that she receive the necessary interventions.
Eating disorders have become prevalent in the world today. They exist in both men and women; however they are more common in women. Clearly, eating disorders in female adolescents and young adults with type 1 diabetes have become more common as well. In a cross sectional study performed in Canada (Jones, JM et. al, British Medical Journal 2000: 320: 1563-1566) it was noted that eating disorders were nearly two times as common in girls 12-19 years of age with type 1 diabetes mellitus compared to their non-diabetic counterparts. Of even more importance, hb A1c levels were notably higher in type 1 diabetes patients who had eating disorders than in those who did not (9.4% as compared to 8.6%, p value=0.04). It also was noted that after dieting, insulin omission was the most common weight loss method for these female adolescents.
Additional information gleaned from a 2008 study (by Goebel-Gabbri et. al in Diabetes Care. 2008; 31:415-419), documented that insulin restriction was directly correlated with increased morbidity and mortality in women with type 1 diabetes. They noted that insulin restriction increased the risk of mortality by a factor of three. In addition, mean age of death was younger among those using insulin restriction as a means of weight loss compared to those who used insulin appropriately (45 years as compared to 58 years, p value <0.01). Those women who omitted insulin also had higher rates of diabetes complications including nephropathy and foot issues.
It is important to understand why omission of insulin is so effective in weight loss in people with type 1 diabetes. Once again, we revert back to the biochemistry of the glycolysis pathway (breakdown of glucose and entrance into the cells). Without insulin, glucose is unable to enter the cells to assist in the creation of energy. The glucose remains in the blood stream and is filtered into the urine. Because of the high amount of glucose solute in the urine, an increase in fluids is required to eliminate it from the urine and increased drinking and urination result (polydipsia and polyuria). These are the typical symptoms of new onset diabetes when no insulin is present. To obtain energy, the body starts breaking down fat (due to the lack of the glucose substrate) and weight loss along with electrolyte abnormalities occur. Thus, in individuals with diabulemia (diabetes + bulimia (binging and purging, in this case, with omission of insulin), weight loss occurs because insulin is selectively omitted to enable the calories from glucose to be lost in the urine and consequently initiate the pathway that metabolizes fat into triglycerides and fatty acids. When fatty acids break down, the development of ketones result with subsequent high risk and probability of diabetic ketoacidosis. Therefore, we have both acute complications of diabetes and diabulemia (hyperglycemia, ketones and possibly Diabetic Ketoacidosis) and the long-term complications of nephropathy, etc., and death.
Physicians have become more educated in terms of eating disorders in their patients. It is only over the last decade that we have come to be more proactive in the recognition and diagnosis of Diabulemia. Thus, it is extremely important for caregivers to note changes in weight, insulin administration, and the development of symptoms of insulin omission (increased drinking, urination, eating, ketones) prior to significant weight loss. Once a person with diabetes develops an eating disorder (with or without insulin omission) it is very difficult to treat both psychologically and medically. Indeed, multidisciplinary teams that include a diabetologists, diabetes educators, dieticians, psychologists, and social workers are required to effectively make inroads in the management of diabulemia. Many diabetes programs have teams to work with these young adults as outpatients. However, if outpatient treatment is deemed unsatisfactory, residential admission is often required. Several examples of facilities that specialize in diabetes and eating disorders include the Renfrew Centers, Cumberland Hospital and Park Nicollet. Clearly these examples are not exhaustive and one must look for centers near your geographic location.
The take home message is that diabulemia is a complex medical and psychological disorder that has short- and long-term consequences. Without treatment, the risk of morbidity and mortality is significant. It is important for caregivers to be alert to any behavior in our adolescent and young adult population that may be suggestive of an eating disorder or diabulemia.
Published On: May 25, 2010