Diabulimia. By: Rafael, Casondra, Yiwen and Silva

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1 Diabulimia By: Rafael, Casondra, Yiwen and Silva

2 What is Diabulimia/ED-DmT1? An eating disorder in a person with diabetes, typically, type 1, wherein the person purposely decreases, delays, or completely omits prescribed insulin doses to lose weight. Restricting insulin induces hyperglycemia in the individual and calorie loss is through the excretion of urine in the form of glucose. Induces Diabetic ketogenesis in the body ED-DMT1:Eating Disorder-Diabetes Mellitus type 1. People suffering from ED-DMT1 may exhibit any number of eating disorder behaviors or they may only manipulate their insulin and otherwise have normal eating patterns.

3 Diabulimia does not have a separate diagnostic code so a person s specific diagnosis will depend on their eating disorder behaviors. The diagnostic manual, DSM-5, classifies: Insulin omission as a purging behavior, therefore it may be coded as bulimia nervosa if the person is binging then restricting insulin. It may be diagnosed as purging disorder if the person is eating normally and restricting insulin Important because if there was just one diagnostic criteria then many people who didn't quite fit under that criteria would feel like they don t actually have a problem and will not feel the need to stop or seek help

4 Pathophysiology Insulin feedback loop determined by blood glucose levels Anabolic Effects Source: g/hormones-dna/hormones-the-missing-link-in-weight-loss/ Source:

Pathophysiology - Insulin Restriction Poor Glycemic control - When plasma glucose levels reach or exceed 180mg/dL, glycosuria develops and polyuria occurs as an attempt to get rid of the excess

5 Pathophysiology - Insulin Restriction Poor Glycemic control - When plasma glucose levels reach or exceed 180mg/dL, glycosuria develops and polyuria occurs as an attempt to get rid of the excess glucose. - Loss of fluid will cause polydipsia and activate the thirst mechanism - High Blood glucose levels cause damage to blood vessels and injure nerve fibers throughout the body especially in the feet and legs

Insulin Restriction As a Weight Loss Strategy Weight gain is associated with Intensive Insulin Treatment (DCCT/EDIC study) Withholding insulin becomes a form of calorie purging Since the cells are

6 Insulin Restriction As a Weight Loss Strategy Weight gain is associated with Intensive Insulin Treatment (DCCT/EDIC study) Withholding insulin becomes a form of calorie purging Since the cells are not taking up glucose, the body interprets it as hunger/starvation and the polyphagia exists With lack of glucose available for the cells, the body uses its own reserves through gluconeogenesis and lipolysis Muscle wasting occurs as a result of using amino acids as gluconeogenic substrates, and FA are utilized from adipose tissue leading to weight loss. The body will try to preserve lean mass and shifts to use of ketone bodies Diabetic Ketoacidosis Source: -grab-wine-not-beer-summer-weight-loss/

7 Source: Wolfsdorf et al. (2014). doi: /pedi.12165

disordered eating. -As many as 35 percent of young adult women with type 1 diabetes met the criteria for a sub-threshold eating disorder.

8 Who is at risk? Statistics show that just having diabetes (type 1 or 2) puts an individual at increased risk for developing an eating disorder or disordered eating. -As many as 35 percent of young adult women with type 1 diabetes met the criteria for a sub-threshold eating disorder. (display symptoms of an eating disorder but do not meet the full diagnostic criteria) -As many as 11 percent of young adult women with type 1 diabetes met the criteria for a full-syndrome eating disorder. -16% of males with type 1 diabetes have disordered eating behaviors

9 Warning Signs Often individuals physical appearance can trigger a need for further investigations. Anxiety about weight or avoidance of being weighed; Bingeing on carbohydrates and sweets Cancelled or infrequent attendance at follow-up diabetic outpatients appointments. Delayed puberty due to interference with the function of the brain. Excessive exercise

10 Symptoms Typically symptoms include a pale appearance, dry lips and cold extremities with signs of malnutrition MOre Signs of diabulimia include: Rapid weight loss Unusual food patterns Obsession with body size and shape ketone smell on the breath and in the urine Unexplained hyperglycemia and frequent micturition. Lethargy

11 Risk Factors Diabulimia is due to a combination of biological, psychological and sociocultural factors. Type 1 Diabetes Family history Gender Athletes Yo-yo dieting Mental illness Trauma

12 Treatment/Recovery Treatment is a multidisciplinary process centered around therapy and education. The 1st step of treatment is to assess the patient medically (Is hospitalization necessary?) Importance of this step is to guide the patient to stability. Once the patient is stable, a structured therapy curriculum is used. Psychological & pharmacological

13 treatment/recovery cont... A combination of individual and family therapy is used to start the road to recovery. Focus of therapy: manage/reduce stress & anxiety, introduce new healthy habits Family therapy is very important for younger patients. Studies have shown that this form of therapy provided a 40-50% higher effectiveness rate in making long term changes) Educating the patient about the importance of proper use of insulin is crucial to recovery. Goal-oriented treatment: start with little changes (health,lifestyle) and build to make long term changes

Role of the Dietitian as part of Interdisciplinary team Assessment: - Nutrition Focused Physical Exam - monitoring signs of malnutrition - brittle hair and loss of hair, dry and pale skin, muscle

14 Role of the Dietitian as part of Interdisciplinary team Assessment: - Nutrition Focused Physical Exam - monitoring signs of malnutrition - brittle hair and loss of hair, dry and pale skin, muscle wasting, fat wasting, signs of micronutrient deficiencies - Diet History and Intake assessment - Meal/ Snack Time - Carb counting and Insulin administration - Lab values and vital signs - Weight trends - Ability to perform ADL Counseling: - Managing diabetes with diet & exercise - Addressing patient s fears about food and weight - Motivational interviewing - Assessing motivation for change - Mindful eating Source:

15 -Content Questions- 1. Why is it important to have specific diagnostics criteria for a person with Diabulimia? (Casondra) 2. How does insulin restriction lead to weight loss? (Silva) 3. What are the potential signs of getting diabulimia?(yiwen) 4. Why is family therapy important especially for young patients? (Rafael)

16 References Callum, A. M., & Lewis, L. M. (2014). Diabulimia among adolescents and young adults with Type 1 diabetes. Clinical Nursing Studies,2(4). doi: /cns.v2n4p12 Colton, P., Rodin, G., Bergenstal, R., & Parkin, C. (2009). Eating Disorders and Diabetes: Introduction and Overview. American Diabetes Association. Doi: /diaspect Davidson, J. (2014). Diabulimia: How eating disorders can affect adolescents with diabetes. Nursing Standard (2014 ), 29(2), 44. Goebel-Fabbri, A. E., Fikkan, J., Franko, D. L., Pearson, K., Anderson, B. J., & Weinger, K. (2008). Insulin restriction and associated morbidity and mortality in women with type 1 diabetes. Diabetes Care, 31(3), dc Haagen, B. (2009). Diabulimia: What it is and how to recognize it in critical care. Dimensions of Critical Care Nursing : DCCN., 28(4), Nelms, M., Sucher, K. P., & Lacey, K. (2015). Nutrition therapy and pathophysiology Cengage Learning. Purnell, J. Q., Zinman, B., Brunzell, J. D., & DCCT/EDIC Research Group. (2013). The effect of excess weight gain with intensive diabetes mellitus treatment on cardiovascular disease risk factors and atherosclerosis in type 1 diabetes mellitus: Results from the diabetes control and complications Trial/Epidemiology of diabetes interventions and complications study (DCCT/EDIC) study. Circulation, 127(2), /CIRCULATIONAHA Ruth-Sahd, L. A., Schneider, M., & Haagen, B. (2009). Diabulimia: What it is and how to recognize it in critical care. Dimensions of Critical Care Nursing : DCCN, 28(4), ; quiz /DCC.0b013e3181a473fe Wolfsdorf, J. I., Allgrove, J., Craig, M. E., Edge, J., Glaser, N., Jain, V.,... Sperling, M. A. (2014). Diabetic ketoacidosis and hyperglycemic hyperosmolar state. Pediatric Diabetes, 15(S20),

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