Diabulimia (a

portmanteau In linguistics, a blend—also known as a blend word, lexical blend, or portmanteau—is a word formed by combining the meanings, and parts of the sounds, of two or more words together.

of ''

diabetes Diabetes mellitus, commonly known as diabetes, is a group of common endocrine diseases characterized by sustained high blood sugar levels. Diabetes is due to either the pancreas not producing enough of the hormone insulin, or the cells of th ...

'' and ''

bulimia Bulimia nervosa, also known simply as bulimia, is an eating disorder characterized by binge eating (eating large quantities of food in a short period of time, often feeling out of control) followed by compensatory behaviors, such as self-induc ...

''), also known as ED-DMT1 (eating disorder-diabetes mellitus type 1) in the US or T1ED (type 1 eating disorder) in the UK, is an

eating disorder An eating disorder is a mental disorder defined by abnormal eating behaviors that adversely affect a person's health, physical or mental health, mental health. These behaviors may include eating too much food or too little food. Types of eatin ...

in which people with

type 1 diabetes Type 1 diabetes (T1D), formerly known as juvenile diabetes, is an autoimmune disease that occurs when the body's immune system destroys pancreatic cells (beta cells). In healthy persons, beta cells produce insulin. Insulin is a hormone require ...

deliberately give themselves less

insulin Insulin (, from Latin ''insula'', 'island') is a peptide hormone produced by beta cells of the pancreatic islets encoded in humans by the insulin (''INS)'' gene. It is the main Anabolism, anabolic hormone of the body. It regulates the metabol ...

than they need or stop taking it altogether for the purpose of

weight loss Weight loss, in the context of medicine, health, or physical fitness, refers to a reduction of the total body mass, by a mean loss of fluid, body fat (adipose tissue), or lean mass (namely bone mineral deposits, muscle, tendon, and other conn ...

. Diabulimia is not recognized as a formal psychiatric diagnosis in the

DSM-5 The ''Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition'' (DSM-5), is the 2013 update to the '' Diagnostic and Statistical Manual of Mental Disorders'', the taxonomic and diagnostic tool published by the American Psychiat ...

. Because of this, some in the medical or psychiatric communities use the phrases "disturbed eating behavior" or "disordered eating behavior" (DEB in both cases) and

disordered eating Disordered eating describes a variety of abnormal eating behaviors that, by themselves, do not warrant diagnosis of an eating disorder. Disordered eating includes behaviors that are common features of eating disorders, such as: * Chronic restra ...

(DE) are quite common in medical and psychiatric literature addressing patients who have type 1 diabetes and manipulate insulin doses to control weight along with exhibiting bulimic behavior. Diabulimia is caused by a range of factors relating to

body image Body image is a person's thoughts, feelings and perception of the aesthetics or sexual attractiveness of their own body. The concept of body image is used in several disciplines, including neuroscience, psychology, medicine, psychiatry, psycho ...

, the regular use of

, and

emotional well-being Emotional well-being (EWB) is a field of study that focuses on the emotional aspects of human experience and is recognized as a crucial component of overall health and quality of life. It is often used interchangeably with, but is distinct from ment ...

. Insulin can cause weight gain, and a person who restricts insulin may lose weight. Insulin restriction can lead to the common symptoms of uncontrolled

hyperglycemia Hyperglycemia is a condition where unusually high amount of glucose is present in blood. It is defined as blood glucose level exceeding 6.9 mmol/L (125 mg/dL) after fasting for 8 hours or 10 mmol/L (180 mg/dL) 2 hours after eating. Blood gluc ...

, which risks complications and a shorter life expectancy. Treatment involves cognitive behavioral therapy, and other support services offered by a multidisciplinary team who work both in diabetes medicine and on eating disorders. Diabulimia is most common in young people, and most of the severe cases tend to occur in women. Research into effective management strategies is ongoing, with a growing medical consensus on the importance of early intervention with specialist teams. People with diabulimia often suffer both from clinicians and from friends and family, partly due to the lack of understanding of the condition.

Signs and symptoms

A person with diabulimia, especially if not treated early, can result in negative effects on the body. Of diabetics who have a DEB, some intentionally misuse insulin to control weight. This may also involve irregular eating patterns. Suspension of insulin combined with overeating can result in

ketoacidosis Ketoacidosis is a metabolic state caused by uncontrolled production of ketone bodies that cause a metabolic acidosis. While ketosis refers to any elevation of blood ketones, ketoacidosis is a specific pathologic condition that results in changes i ...

. Multiple hospitalizations for ketoacidosis or

are cues to screen for an underlying emotional conflict.

Short term

The short-term symptoms of diabulimia are: * Frequent and

excessive urination Frequent urination, or urinary frequency (sometimes called pollakiuria), is the need to urinate more often than usual. Diuretics are medications that increase urinary frequency. Nocturia is the need of frequent urination at night. The most common c ...

* Frequent and excessive thirst * Frequent and excessive hunger * High blood glucose levels (often over 600 mg/dL or 33 mmol/L) *

Weakness Weakness is a symptom of many different medical conditions. The causes are many and can be divided into conditions that have true or perceived muscle weakness. True muscle weakness is a primary symptom of a variety of skeletal muscle diseases, ...

Fatigue Fatigue is a state of tiredness (which is not sleepiness), exhaustion or loss of energy. It is a signs and symptoms, symptom of any of various diseases; it is not a disease in itself. Fatigue (in the medical sense) is sometimes associated wit ...

* Large amounts of glucose in the urine (glycosuria) * Inability to

concentrate A concentrate is a form of Chemical substance, substance that has had the majority of its diluting agent or diluent (in the case of a liquid: the solvent) removed, such that the substance becomes the majority of the composition. Typically, this w ...

Electrolyte disturbance Electrolyte imbalance, or water-electrolyte imbalance, is an abnormality in the concentration of electrolytes in the body. Electrolytes play a vital role in maintaining homeostasis in the body. They help to regulate heart and neurological function ...

* Severe

ketonuria Ketonuria is a medical condition in which ketone bodies are present in the urine. It is seen in conditions in which the body produces excess ketones as an indication that it is using an alternative source of energy. It is seen during starvation o ...

, and, in DKA, severe ketonemia * Low sodium levels

Medium term

These are the medium-term symptoms of diabulimia. They are prevalent when diabulimia has not been treated and hence also include the short-term symptoms. *

Muscle atrophy Muscle atrophy is the loss of skeletal muscle mass. It can be caused by immobility, aging, malnutrition, medications, or a wide range of injuries or diseases that impact the musculoskeletal or nervous system. Muscle atrophy leads to muscle weakne ...

GERD Gastroesophageal reflux disease (GERD) or gastro-oesophageal reflux disease (GORD) is a chronic upper gastrointestinal disease in which stomach content persistently and regularly flows up into the esophagus, resulting in symptoms and/or ...

Indigestion Indigestion, also known as dyspepsia or upset stomach, is a condition of impaired digestion. Symptoms may include upper abdominal fullness, heartburn, nausea, belching, or upper abdominal pain. People may also experience feeling full earlier ...

* Severe

Proteinuria Proteinuria is the presence of excess proteins in the urine. In healthy persons, urine contains very little protein, less than 150 mg/day; an excess is suggestive of illness. Excess protein in the urine often causes the urine to become fo ...

* Moderate to severe

dehydration In physiology, dehydration is a lack of total body water that disrupts metabolic processes. It occurs when free water loss exceeds intake, often resulting from excessive sweating, health conditions, or inadequate consumption of water. Mild deh ...

Edema Edema (American English), also spelled oedema (British English), and also known as fluid retention, swelling, dropsy and hydropsy, is the build-up of fluid in the body's tissue (biology), tissue. Most commonly, the legs or arms are affected. S ...

with fluid replacement *

High cholesterol Hypercholesterolemia, also called high cholesterol, is the presence of high levels of cholesterol in the blood. It is a form of hyperlipidemia (high levels of lipids in the blood), hyperlipoproteinemia (high levels of lipoproteins in the blood), ...

* A1c of 9.0 or higher

Long term

If a person with type 1 diabetes who has diabulimia has the disease for more than a short time—usually due to alternating phases during which insulin is injected properly and relapses during which they have diabulimia—then the following longer-term symptoms can be expected: *

Delayed puberty Delayed puberty is when a person lacks or has incomplete development of specific sexual characteristics past the usual age of onset of puberty. The person may have no physical or hormone, hormonal signs that puberty has begun. In the United States ...

(and

dysmenorrhoea Dysmenorrhea, also known as period pain, painful periods or menstrual cramps, is pain during menstruation. Its usual onset occurs around the time that menstruation begins. Symptoms typically last less than three days. The pain is usually in the ...

amenorrhoea Amenorrhea or amenorrhoea is the absence of a menstrual period in a female organism who has reached reproductive age. Physiological states of amenorrhoea are most commonly seen during pregnancy and lactation (breastfeeding). In humans, it is wher ...

in women) in young people *Severe

kidney damage Kidney disease, or renal disease, technically referred to as nephropathy, is damage to or disease of a kidney. Nephritis is an inflammatory kidney disease and has several types according to the location of the inflammation. Inflammation can b ...

: high blood sugar can overwork the

kidney In humans, the kidneys are two reddish-brown bean-shaped blood-filtering organ (anatomy), organs that are a multilobar, multipapillary form of mammalian kidneys, usually without signs of external lobulation. They are located on the left and rig ...

s, eventually leading to

kidney failure Kidney failure, also known as renal failure or end-stage renal disease (ESRD), is a medical condition in which the kidneys can no longer adequately filter waste products from the blood, functioning at less than 15% of normal levels. Kidney fa ...

and the need for a

kidney transplant Kidney transplant or renal transplant is the organ transplant of a kidney into a patient with end-stage kidney disease (ESRD). Kidney transplant is typically classified as deceased-donor (formerly known as cadaveric) or living-donor transplantat ...

* Severe

neuropathy Peripheral neuropathy, often shortened to neuropathy, refers to damage or disease affecting the nerves. Damage to nerves may impair sensation, movement, gland function, and/or organ function depending on which nerve fibers are affected. Neuropa ...

(nerve damage to hands and feet) * Extreme

fatigue Fatigue is a state of tiredness (which is not sleepiness), exhaustion or loss of energy. It is a signs and symptoms, symptom of any of various diseases; it is not a disease in itself. Fatigue (in the medical sense) is sometimes associated wit ...

(during blood sugars controlled phases) *

Heart problems Cardiovascular disease (CVD) is any disease involving the heart or blood vessels. CVDs constitute a class of diseases that includes: coronary artery diseases (e.g. angina pectoris, angina, myocardial infarction, heart attack), heart failure, ...

* Retinal damage and subsequent vision problems *

(hypercholesterolaemia) *

Osteoporosis Osteoporosis is a systemic skeletal disorder characterized by low bone mass, micro-architectural deterioration of bone tissue leading to more porous bone, and consequent increase in Bone fracture, fracture risk. It is the most common reason f ...

Death Death is the end of life; the irreversible cessation of all biological functions that sustain a living organism. Death eventually and inevitably occurs in all organisms. The remains of a former organism normally begin to decompose sh ...

Causes

Diabulimia

Diabulimia is caused by a range of factors relating to

, the regular use of

, and

. The long-term management of type 1 diabetes often involves dietary restrictions for control of

blood sugar level The blood sugar level, blood sugar concentration, blood glucose level, or glycemia is the measure of glucose concentrated in the blood. The body tightly regulates blood glucose levels as a part of metabolic homeostasis. For a 70 kg (1 ...

, which can raise a negative attention to diet. There is often a focus on the fact that insulin can cause weight gain, and that not using insulin can cause weight loss. For example, a person with type 1 diabetes may have experienced weight loss before the diagnosis, followed by weight gain when beginning treatment with insulin. This may lead to increased body dissatisfaction and preoccupation with weight loss. This increases the risk of eating disorders such as

anorexia nervosa Anorexia nervosa (AN), often referred to simply as anorexia, is an eating disorder characterized by Calorie restriction, food restriction, body image disturbance, fear of gaining weight, and an overpowering desire to be thin. Individuals wit ...

and

bulimia nervosa Bulimia nervosa, also known simply as bulimia, is an eating disorder characterized by binge eating (eating large quantities of food in a short period of time, often feeling out of control) followed by compensatory behaviors, such as self-indu ...

. The vast majority of people with diabulimia are aware of the negative side effects that

can cause. Skipping insulin can lead to weight loss without side effects at first, but the risk of side effects gets progressively worse - by this time, it is more difficult to change behavior. Weight gain can cause individuals to fear insulin as it is often seen as the root of their low self-esteem. Low self-esteem can lead to depression or anxiety about body image that contributes to difficulty with diabetes management. Often, individuals often think diabulimia is less common than it is and do not know how difficult it is to overcome. Unlike vomiting or starving, there is sometimes no clear action or willpower involved. Often, individuals will refuse to believe in the diagnosis or the long-term effects.

Eating Disorders

Eating disorders can stem from a variety of factors, extending beyond individual predispositions. Influences from Western culture, childhood sexual abuse, specific personality traits, and neurobiological factors are identified as additional contributors to the development of eating disorders. Western cultural influence plays a significant role, often promoting unrealistic beauty standards and societal pressures related to body image. The pervasive impact of media, emphasizing certain body ideals, can contribute to the development of unhealthy eating patterns. Childhood sexual abuse is recognized as a traumatic experience that may lead to the development of eating disorders. The psychological effects of such abuse can manifest in disordered eating as individuals cope with emotional distress through their relationship with food. Certain personality traits, such as perfectionism, low self-esteem, or a strong desire for control, are associated with an increased vulnerability to eating disorders. These traits may influence the way individuals perceive and interact with their bodies and food. Additionally, emerging evidence in the field of neurobiology suggests that there are biological factors contributing to the development and maintenance of eating disorders. Neurochemical imbalances and alterations in brain function may influence appetite regulation, reinforcing disordered eating behaviors. Understanding the multifaceted nature of these causes is crucial for comprehensive prevention and treatment strategies.

Prognosis

Diabulimia appears to lower

life expectancy Human life expectancy is a statistical measure of the estimate of the average remaining years of life at a given age. The most commonly used measure is ''life expectancy at birth'' (LEB, or in demographic notation ''e''0, where '' ...

compared to other patients with type 1 diabetes, with the

mean A mean is a quantity representing the "center" of a collection of numbers and is intermediate to the extreme values of the set of numbers. There are several kinds of means (or "measures of central tendency") in mathematics, especially in statist ...

age of death around 45 (13 years lower than that for type 1 diabetes without an eating disorder). This reduced life expectancy is

correlated In statistics, correlation or dependence is any statistical relationship, whether causal or not, between two random variables or bivariate data. Although in the broadest sense, "correlation" may indicate any type of association, in statistic ...

with the severity of eating disorder behaviors.

Treatment

Treatment for diabulimia has two goals: stabilizing diabetes by increasing insulin intake and addressing the underlying eating disorder. The standard approach for the treatment of two complex conditions involves a multidisciplinary team of professionals. This team may include an

endocrinologist Endocrinology (from ''endocrine'' + '' -ology'') is a branch of biology and medicine dealing with the endocrine system, its diseases, and its specific secretions known as hormones. It is also concerned with the integration of developmental events ...

, a

psychiatrist A psychiatrist is a physician who specializes in psychiatry. Psychiatrists are physicians who evaluate patients to determine whether their symptoms are the result of a physical illness, a combination of physical and mental ailments or strictly ...

, a

psychologist A psychologist is a professional who practices psychology and studies mental states, perceptual, cognitive, emotional, and social processes and behavior. Their work often involves the experimentation, observation, and explanation, interpretatio ...

, and a

dietician A dietitian, medical dietitian, or dietician is an expert in identifying and treating disease-related malnutrition and in conducting medical nutrition therapy, for example designing an enteral tube feeding regimen or mitigating the effects of ...

Eating Disorder

To address the underlying eating disorder psychosocial interventions such as cognitive behavioral therapy, motivational therapy, problem-solving therapy, coping skills training, and family behavior therapy have all been shown to improve treatment adherence and achieve good glycemic control. It has been observed that addressing psychological needs improves HbA1c by 0.5%–1% in adults with T2DM. Useful therapies may involve

cognitive behavioral therapy Cognitive behavioral therapy (CBT) is a form of psychotherapy that aims to reduce symptoms of various mental health conditions, primarily depression, PTSD, and anxiety disorders. Cognitive behavioral therapy focuses on challenging and chang ...

. Cognitive behavioral therapy focuses on changing unhealthy thinking surrounding the use of insulin. Family involvement and

family therapy Family therapy (also referred to as family counseling, family systems therapy, marriage and family therapy, couple and family therapy) is a branch of psychotherapy focused on families and couples in intimate relationships to nurture change and ...

is helpful for long-term maintenance of good behaviors with taking insulin. A positive mindset to recovery, and connection with others who have experienced diabulimia, increases the probability of successful recovery.

Insulin

Individuals diagnosed with type 1 diabetes typically need to administer insulin on a daily basis, frequently four to five injections throughout the day. The methods of insulin injection vary, including the use of a syringe and needle, an insulin delivery pen, or an insulin pump. Finding the optimal insulin dose to effectively lower one's blood glucose to the desired levels may take some time, even with the assistance of healthcare professionals. This process involves careful adjustment and monitoring to achieve the best outcomes for managing diabetes. Even with treatment, relapse is common (some estimate over 50% relapse within six years), requiring long-term reassessment for early intervention.

Epidemiology

Diabulimia is most common in women, and in people between 15 and 30 years old. Around 40% of men with type 1 diabetes may have skipped insulin injection at least once, and around 20% of women. Some studies have found that up to 60% of people with type 1 diabetes deliberately restrict insulin at some point. Many articles and studies further conclude that diabetic females have, on average, higher

body mass index Body mass index (BMI) is a value derived from the mass (Mass versus weight, weight) and height of a person. The BMI is defined as the human body weight, body mass divided by the square (algebra), square of the human height, body height, and is ...

(BMI) than their nondiabetic counterparts. Girls and young adult women with higher BMIs are also shown to be more likely to have disordered eating behavior (DEB). Many authoritative articles show that preteen and teenage girls with type 1 diabetes have significantly higher rates of eating disorders of all types than do girls without diabetes.

History

Diabulimia is not currently recognised in the

. Current diagnoses are based on the idea of insulin restriction being a feature of existing

and

. Diabulimia is gaining notability within

scientific research The scientific method is an empirical method for acquiring knowledge that has been referred to while doing science since at least the 17th century. Historically, it was developed through the centuries from the ancient and medieval world. The ...

. In 2019,

NHS England NHS England, formally the NHS Commissioning Board for England, is an executive non-departmental public body of the Department of Health and Social Care. It oversees the budget, planning, delivery and day-to-day operation of the commissioning si ...

began trialling specialist diabulimia

clinic A clinic (or outpatient clinic or ambulatory care clinic) is a health facility that is primarily focused on the care of outpatients. Clinics can be privately operated or publicly managed and funded. They typically cover the primary care needs ...

s. Whilst access to eating disorder clinics is improving, access to specialist diabulimia services is not widely available.

Society and culture

A lack of recognition of diabulimia by

clinician A clinician is a health care professional typically employed at a skilled nursing facility or clinic. Clinicians work directly with patients rather than in a laboratory, community health setting or in research. A clinician may diagnose, treat a ...

s leads to generally negative medical interactions. There is also a lack of

public awareness In public relations and communication science, publics are groups of individual people, and the public (a.k.a. the general public) is the totality of such groupings. This is a different concept to the sociological concept of the ''Öffentlichke ...

. A lack of medical understanding creates

social stigma Stigma, originally referring to the visible marking of people considered inferior, has evolved to mean a negative perception or sense of disapproval that a society places on a group or individual based on certain characteristics such as their ...

. Because diabulimia tends not to involve significant eating restriction like

, or purging as in

, some do not recognise the significance of diabulimia. A

BBC The British Broadcasting Corporation (BBC) is a British public service broadcaster headquartered at Broadcasting House in London, England. Originally established in 1922 as the British Broadcasting Company, it evolved into its current sta ...

documentary A documentary film (often described simply as a documentary) is a nonfiction Film, motion picture intended to "document reality, primarily for instruction, education or maintaining a Recorded history, historical record". The American author and ...

in 2017 caused a significant increase in requests for specialist medical training for diabulimia, and improved public awareness.

References

{{Reflist, colwidth=30em Eating disorders Complications of diabetes

Signs and symptoms

Short term

Medium term

Long term

Causes

Diabulimia

Eating Disorders

Prognosis

Treatment

Eating Disorder

Insulin

Epidemiology

History

Society and culture

See also

References