Trakia Journal of Sciences, No 2, pp 187-195, 2019 Copyright © 2019 Trakia University Available online at: http://www.uni-sz.bg ISSN 1313-7069 (print) ISSN 1313-3551 (online) doi:10.15547/tjs.2019.02.013

Review DIABULIMIA - CULTURAL DETERMINANTS OF EATING DISORDERS

B. Hoffmann*

Institute of Applied Social Sciences, University of Warsaw, Poland

ABSTRACT Eating disorders are becoming an increasingly common problem. This problem becomes particularly dangerous when it concerns specific groups in which the occurrence of any nutritional irregularities constitutes a serious threat to health and even life. This is the case for diabulimia, which I will present in more detail in this article. Personality predispositions and socio-cultural factors are determined as the main risk factors of development of eating disorders, inclusive diabulimia.

Key words: diabulimia, eating disorders, -dependent , risk factor, appearance, addiction, consumer culture.

Eating disorders are becoming an increasingly And so, already from the records of common problem that involves more and more Hippocrates, you could learn about the morbid social groups. The most frequently described abstention from eating, in relation to which the disorders include anorexia and bulimia; terms: asitia and inedia were used. In turn, however the problem goes beyond these Galen drew attention to this disorder, referring entities of disease. Although atypical forms of it to his concept of humoral fluids conditioning eating disorders do not meet all diagnostic the state of the organism. According to Galen, criteria, they constitute a significant individual gastrointestinal dysfunction was supposed to and social problem. This problem becomes be the cause of . In the particularly dangerous when it concerns following centuries, the perception of specific groups in which the occurrence of any abstaining from eating has changed. In the nutritional irregularities constitutes a serious Middle Ages, people refusing food were threat to health and even life. This is the case treated as exceptional, often holy, living thanks for diabulimia, which I will present in more to religious zeal and strong faith (2). As a detail in this article. result of the ongoing cultural changes of the Renaissance, there has been a departure from EATING DISORDERS – SHORT the interpretation of hunger strikes through the CHARACTERISTICS prism of religion. This was to some extent Although many times you may find the resumed during the Baroque period. Then the opinion that eating disorders are closely related refusal to accept food was part of the rituals to contemporary cultural processes, models associated with mourning, and was seen as the and aesthetic ideals (1), traces of existing way to achieve a union with Christ (3). Thanks nutrition problems have also been found in the to the development of medicine and natural past, even though in former times they were sciences in the Enlightenment, there has been not perceived as disorders. significant progress in the "diagnosis" of ______anorexia nervosa. In 1840 the study of the *Correspondence to: Dr hab. Beata Hoffmann, French physician Fleury Imbert and his work Institute of Applied Social Sciences, University of entitled Traité théorique et pratique des Warsaw, Poland, [email protected] maladies des femmes, not only distinguished

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HOFFMANN B. gastric anorexia (anorexia gastrique) and nerve "appetite" (9). Interestingly, this entity of anorexia (anorexia nerveuse), but also drew was not only the subject of his attention to the fact that this problem professional practice, but his own experience. concerned women. A decade later, in 1860, Even as a child, Bratman was forced to Louis - Victor Marce published an article, eliminate wheat and dairy products from his which showed that it is certainly not the menu. Gradually, the fear of eating products digestive tract that is responsible for anorexia that could harm him caused a strong control of but a certain type of delirium (4). everything he consumed. In the following years, the concern about the only diet that is Subsequently, the "new disorder" became the right in his opinion, as well as a way of subject of independent research by the doctors: preparing and consuming dishes, took a form the Englishman, Sir William Wishey Gull and of obsession. The so-called healthy diet has the Frenchman Ernest Charles Laseque. First, become the sole purpose of his life. Many in 1868, the term Apepsia histeria was used to hours of daily involvement in preparing meals describe anorexia, then it was soon replaced getting familiar with the literature on healthy with the term "Anorexia". The characteristic of eating, health-food stores, and collecting new, a new disease entity has been translated into more and more restrictive diets, led to several languages and appeared in professional restrictive dietary limitations. Concentration on American, German, Italian and Dutch literature the diet became the only activity of Bratman (5). Since then, anorexia began to be treated as and the only goal he aspired to. a mental illness, the effects of which are also felt by the physical side of a human body. Initially, he avoided friends and acquaintances to finally isolate himself completely, At the beginning of the twentieth century, a committing himself to the only correct, in his French neurologist and one of the founders of opinion, occupation - preparing the right the - Jean-Martin Charcot and his meals. Graduation of medical studies and student - Pierre Janet and Siegmund Freud taking up a job, contributed to Bratman’s drew attention to the importance of both change of perception of his own person. psychological factors, and the family Meeting in his office patients who rigorously environment in the development of anorexia. adhered to diets, he noticed an analogy There were also views that emphasized the between their behavior and his own one. This organic basis of this disease. The German prompted him to classify this problem as a doctor, a pathologist - Morris Simmonds health disorder. became an advocate of such view (6). This view will divert attention from the Diabulimia is definitely a less known eating psychological conditions of anorexia (7) for disorder than anorexia, bulimia or orthorexia. many years to come. The term "diabulimia" arose from the combination of two words: diabetes and In the 1960s of twentieth century, due to the bulimia (one of the eating disorders). Although development of psychology and humanistic in the popular press, the term "diabulimia" psychiatry, the search for psychological appeared in 2007 (10), the problem of this type foundations for the development of anorexia of disorder was already described in the 1970s returned. In the following decades, there was and 1980s (11), in current medical an increased interest in this disorder, and most classifications, including such as DSM- IV and importantly, the attitude of doctors and ICD-10, diabulimia does not occur. It does not therapists to anorexia nervosa has changed. change the fact that it is a dangerous phenomenon, leading to very serious health Among the theories attempting to explain the consequences, and even to death (12). In causes of eating disorders, psychological, addition, it is worth emphasizing that biological and social concepts gained diabulimia affects young people who are often popularity. As the research progressed, in the phase of their adolescence. Because this subcategories of anorexia were distinguished. form of eating disorder refers to a specific A special place was taken by bulimia, group in which the occurrence of any distinguished and described in 1979 by the nutritional irregularities becomes particularly English doctor - Gerald Russell (8). dangerous, it requires both publicity as well as In 1997, the doctor Steven Bratman used the appropriate preventive actions. term "Orthorexia nervosa" for the first time, where ortho means "correct", and orexis -

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HOFFMANN B. DEFINITION CRITERIA (insulin slowly absorbed in the suspension, According to the definition of the National which is administered once a day). The Eating Disorders Association, diabulimia is an treatment requires from a patient several eating disorder that involves deliberately subcutaneous injections of the drug in solution omitting insulin doses to reduce body weight and systematic, repeated examination of or prevent gain of weight in people with type 1 glucose level in blood. The basic method of the diabetes (13). These patients give themselves treatment of is insulin therapy less insulin than their body needs, which performed by repeated injections of insulin or becomes dangerous for health and even life. by means of continuous subcutaneous infusion with a personal insulin pump (16). This type of At this point the question arises, what is the diabetes most frequently occur among children "mechanism" of in this case? If the and adolescents. It is one of the most common body lacks insulin, it is not able to draw energy chronic diseases of the age of adolescence. from the carbohydrates it was provided. There is a dynamic increase in the incidence of Carbohydrates, that are sugars, are a kind of diabetes in the world and in Poland (17). fuel for muscles and brain. According to the recommendations of dieticians, they should be The typical symptoms of type 1 diabetes are: the basis for the menu. The problem is that the , , weight loss, drowsiness, mere supply of carbohydrates to the body and and progressive . The digesting them does not feed us yet. That is the treatment aims at the best alignment of insulin which is needed so that the energy diabetes, because it is a key element that obtained from carbohydrates, strengthen the reduces the risk of developing serious cells of our body. If we do not have it, the complications (18). energy is excreted together with the urine, which results in large amounts of sugar in the People with type 1 diabetes must regularly urine of type 1 diabetes. But the body is unable monitor the level of blood glucose to function without any fuel in the long run, so (glycaemia), follow healthy eating habits with in the absence of insulin, it switches to use fat. the restriction of simple sugars, and use insulin And not only this supplied with food, but also therapy. This causes a change in a style of their that stored for a rainy hour, in the form of current life, the threat of depressive episodes adipose tissue. Therefore, people who do not (especially among adolescents) (19), as well as have their own insulin and do not provide it anxiety symptoms. The occurrence of these from the outside, regardless of how much they disorders may result in impediments in the eat, and so lose kilograms. The mechanism of performance of everyday activities and affect this weight loss is double - the energy cannot the quality of social functioning (20). be used, and in addition, the body reaches for DIAGNOSTIC CRITERIA fat, because it must be somehow nourished. As Diagnostic criteria for diabulimia are similar to a result of burning fat in blood, ketone bodies those adopted by the Diagnostic and Statistical appear, which constitute an alternative source Manual (DSM) for the diagnosis of eating of energy for the brain and heart, but are not disorders in people without carbohydrate the source of energy for the cells of muscles, disorders, i.e. anorexia nervosa (AN), bulimia for example. Thus, in the absence of insulin, nervosa (BN) or eating disorders defined we are able to survive for some time - because otherwise (EDNOS, eating disorder not the brain gets substitute fuel, but the insulin- otherwise specified) (21). Diagnosis of this dependent cells (the majority in a human body) disorder requires a detailed distinction from are undernourished (14). other eating disorders. It should be also DIABETES MELLITUS TYPE 1 emphasized that in a case of eating disorders (INSULIN-DEPENDENT DIABETES) occurring in diabetics, these problems are The underlying cause of type 1 diabetes is a intensified, because in one person two diseases chronic autoimmune disease process leading to overlap, which lead to catastrophic effects for the slow destruction of insulin producing beta an organism. cells, as a result of which the body is not being Although these disorders differ in symptoms, able to produce insulin itself (15). The disease they have similar clinical features including is treated by administering throughout the psychopathological features and obsession whole life of a patient, the insulin with a short about body shape and body weight are visible duration of action during mealtime throughout next to cognitive distortions such as changes in a day, as well as the insulin with a long-acting, the (22). Quite often, however, nonpeak analogue - so-called the basal level Trakia Journal of Sciences, Vol. 17, № 2, 2019 189

HOFFMANN B. diabulimics, in addition to reducing insulin first stage, dehydration of the body, weight doses, also display additional behaviors, loss caused by, among others, atrophy of typical for anorexia and bulimia, such as: muscles. At the third stage it comes to following restrictive diets, even starvation, damage, sight damage, which can even lead to provoking vomiting, use of laxatives. blindness, retinopathy, nephropathy, , and Symptoms of diabulimia autonomic neuropathy. In addition one feels The presence of the following factors should the extreme fatigue. prompt to suspect eating disorders in a patient with diabetes: DIABULIMIC THAT IS WHO? • persistent high hemoglobin A1c Scientific research shows that diabulimia, as (glycosylated hemoglobin) well as other eating disorders, affects mostly • women (26). This is explained by the fact that • recurrent episodes of ketoacidosis women to the greater extent than men attach • high levels of HbA1c, which can cause importance to the external appearance, irregular menstruation and , and including a well-proportioned, slim figure. Thus, they try to control body weight by • unreliable blood glucose monitoring that limiting food. This view is indeed confirmed indicates irregularities in the documentation of by statistics, but it is increasingly emphasized glucose measurements that this phenomenon also occurs in men (27). • cancelled or rare control visits of diabetic However, they strive to reduce body weight patients not only through poor nutrition, but above all • low BMI values and low content of fat through too intense physical exercise. The • nutritional behaviors similar to people with researchers point out that the problem of deliberately omitting insulin dosing may • excessive concentration on the accurate concern from 15 to even 40% of young counting and control of the number of diabetics, both sexes (28). The problem affects carbohydrate exchangers mostly teenagers during their puberty (29), and • not keeping a self-control diary interesting cases have been described in • dissatisfaction or lack of acceptance of the professional literature (30). own body • noticeable concentration on the external DIABULIMIA PREDISPOSITIONS appearance Personality predispositions and socio-cultural • high level of focus on food and related factors are determined as the main risk factors activities of development of eating disorders. • use of alternative diets (e.g. vegetarianism, Personality conditions affecting development veganism, elimination of gluten without of diabulimia, similarly to anorexia or Pro-ana medical indications, protein diet) behaviors (31), include: negative self-esteem • very high level of physical activity (23) and tendency towards other compulsive "There are also often noticeable changes in the behaviors (32), tendency to suppress emotions, mood and well-being of these patients i.e. low degree of autonomy, perfectionism, low lowered mood, depression, apathy, lack of resistance to stress or so-called external willingness to perform daily activities, fatigue, location of the sense of control (33). emotional lability (mood swings), putting too The socio-cultural conditions include, above high demands on themselves, excessive all, family factors and social factors inherent in scrupulousness and duty, tendencies for strong the wider environment of an individual, as well control "(24). as in the culture in which his/ her life runs. PHASES OF DIABULIMIA Strong subordination to the family system, DEVELOPMENT (25) parents’ overprotection, vaguely defined In the source literature there were boundaries in relations among family members distinguished three stages of diabulimia and the role of a child in the family system, development along with accompanying denial of conflicts and difficulties in solving symptoms and health consequences. The first them, stiff behavior, fear of change, involving stage (so-called initial) includes symptoms a child into the conflict between parents and such as headache, , increased entering in coalition with one of them (34), all drowsiness, high blood glucose, increased these heighten the danger of falling into the thirst and frequent urination. The second stage diabulimia. is intensified by the symptoms occurring in the 190 Trakia Journal of Sciences, Vol. 17, № 2, 2019

HOFFMANN B. The factors triggering the occurrence of the For centuries, a family was the most important, disease include critical remarks about even the only area of activities undertaken by a appearance and fatness, coming from the woman, defining her relationship with other nearest environment, weight loss trends people and social groups, deciding about her popular among peers, as well as family social position, as well as defining her identity behavior, reinforcing abnormal food-related and constituting the criterion for her behaviors. Here I mean these factors that create evaluation. That was a family that shaped a dependencies in the family based on the woman, influenced her behaviors, aspirations feedback model. As Jolanta Rogala - and ways of perceiving the world. Social and Obłękowska emphasizes, "one of the most family roles were strictly defined, imposed in important concepts describing the dynamics of advance and constituted the dominant a family is the concept of the feedback loop, component of a human personality (39). transferred to social sciences from cybernetics, which means replacing the linear cause and Consumer culture began to control the forms effect dependency by the circular dependency. of "existence" (40), making a body the What does it mean? Family members influence supreme organ of consumption. In times of on each other, but these interactions are not strong competition, both in the professional linear in nature, i.e. the cause and effect cannot and personal fields, there is a constant be clearly distinguished, because in a compulsion to create the most desirable social complicated system of family relationships image. Thus, the features associated with what seems to be the cause - may be the result beauty and vitality grow into obsessively of previous interactions "(35). These factors desirable ones. The body gained not only include: focusing on a patient's illness, aesthetic, but above all economic value, while reducing or abandoning family and marital the slim figure became a normative category conflicts related to a child's illness, as well as (41). This 'culture of thinness' exerts enormous all these family behaviors that aim to "hold" pressure, leading to a pathological the family together. Of course, the opposite concentration on diets. The requirements situations may happen, where the illness of a imposed on the modern body apply to a greater family member, here a young person suffering extent to women than men. not only from diabetes, but also diabulimia, According to surveys conducted in Poland by triggers the effect of the family’s CBOS, almost all Poles believe that an disintegration. Polivy and Herman, as well as attractive image and attention to their Latzer together with the research team, pay appearance determines success in personal attention to the importance of a family in the (90%) and professional (92%) life. The same sense of the self-esteem in adolescents and studies show that their own appearance is existence of factors so much predisposing to important for almost all respondents, although development of bulimia as: humiliation, it loses importance as the age of respondents excessive criticism by parents, lack of increases, but even among respondents over emotional support, disturbed communication in 65, 80% declare that their own appearance is a family ( 36), limiting the autonomy of an of great importance to them, and in the range individual and too high degree of controlling of 18-24 years, this percentage is 96% (42). (37). Similar results may also be found in other At this point I would like to pay a special countries. attention to socio-environmental factors related Simultaneously, more and more girls and to the culture of the "skinny body", in which women are dissatisfied with their appearance the appearance itself constitutes a determinant (43). The conviction that the external of a life success, brings recognition and appearance depends largely on ourselves and admiration. regardless the genetic heritage or inherited A human body determined by biology is at the features, we can freely change it, making it same time influenced by culture. In similar to the current canon, has become the contemporary societies, the transfer of product of our times. The ideal, however is knowledge about canons of beauty and ways of most often unattainable and the undertaken caring for it is a significant element of path is endless, because one cannot achieve a socialization in both children and teenagers satisfactory level of perfection. It seems that (38). this belief entails many negative effects, including the already mentioned eating disorders. Trakia Journal of Sciences, Vol. 17, № 2, 2019 191

HOFFMANN B. issue in the life and the only form of self- An important role in the perception of our determination, has been crossed in a dangerous body is played by mass media. Starting from way. Millions of girls, but also adult women the presentation of all "wonderful diets", around the world, although they are not exercises, preparations and cosmetics, through diagnosed by doctors as suffering from one of citing the stories of people who lost a lot of the diseases associated with eating disorders, kilograms (often with "before" and "after" devote a significant part of their time, attention photos) to articles and programs about the and life energy to "discipline their body", benefits of plastic surgery, performing based on this self-esteem values (47) Just as "miracles" "(for an adequate amount of money the boundary between the natural body and the matching everyone to the obligatory "form") artificially created is blurred, the line (44). In the face of an abundance of messages separating the lifestyle from the disease is also of this type, a slim, well-groomed body blurred (48). becomes a normative requirement with a ready recipe for its fulfillment. THE SCALE OF DIABULIMIA Eating disorders may affect about 20% of It is media that promote specific habits, women with type 1 diabetes (49). There are patterns and models to follow. The almost recent reports showing that up to 30% of girls unlimited technical possibilities of television with diabetes in their youthful age suffer from or other visual media make that the presented eating disorders (50). In the observation study image appears to mostly young people as very conducted by Colton and his co-workers, it attractive, worth imitating and above all, was shown that 32.4% of young patients with possible to implement. Without the criticism type 1 diabetes met the criteria of eating that characterizes a mature recipient, a disorders while 8.5% of the examined reported teenager eager for an ideal to imitate, may eating disorders of nonspecific character. In uncritically accept transmitted content addition, it was noted that in 60% of patients, regarding appearance or lifestyle. Media, using the disease started before the age of 25. In the this situation, create a kind of the mass culture study group, the mean time between the onset aimed at young people. By focusing on their of the disease and the occurrence of remission needs, interests and preferences, and making was 4.3 years. The mean length of remission the self-esteem from the very fact of "being" before the recurrence of the disease is 6.5 years young and having typical for youth physical (51). and psychological traits, the media shapes the identity of a young generation. Popular lyrics THE EFFECTS OF DIABULIMIA and heroes are the source of creating a sense of Diabulimia, like other eating disorders, causes community and youthful cultural practices, serious health effects, which are discussed in including those regarding their appearance and detail in the medical literature. At this point, I health (45). just want to point out that in the case of eating disorders occurring in people with type 1 The thinness, assuming the control over eating, diabetes, problems are intensified, because one has become the synonymous of strong will, person has two diseases that lead to effects perfectionism, success and attractiveness (46), which destroy a body. success in peer and wider communities. Intentional skipping of insulin doses can lead Such understanding of corporality also not only to the loss of body weight, which contains a significant contradiction. On the one becomes the target of a patient, but also to very hand there is the cult of a body, its affirmation serious health effects, to coma and even death in the aforementioned mass media (photos, of a patient. articles, programs referring to corporeality or simply "using" a body), on the other hand, a SORTS OF HELP body is constantly kept in check, disciplined by Diabulimia has not been formally recognized diet or gymnastics. Despite warnings against as a disease entity and therefore there are no eating disorders that appear in women's clear diagnostic criteria for its detection. The magazines, important places are still taken by proper preparation of medical personnel is advice on how to slim down and fight with crucial here, both in terms of detecting the someone’s own figure. disorder and its treatment. The basis is to The boundary between taking care of a body identify as soon as possible both, alarm signals for a better wellbeing, maintaining health and of diabulimia and risk factors that lead to its physical fitness and the moment when your development. own appearance becomes the most important 192 Trakia Journal of Sciences, Vol. 17, № 2, 2019

HOFFMANN B. Strategies of diabulimia treatment are the same of which a diabetic lives, as well as their as in the treatment of eating disorders, in the involvement in the subsequent process of whole population. Among the applied forms of treatment. therapy there are mentioned: psychotherapy, pharmacological treatment and hospitalization. Finally, it's worth noting that not all people Psychotherapy (primarily CBT, DBT) (52) in who limit insulin, do it to lose weight. Some diabulimia most often takes on the form of diabetics have psychological barriers to their individual, group or (53). The condition, including cognitive problems, results of the research indicate a greater anxiety associated with injections (needle effectiveness of a family therapy in phobia), mood disorder, social barriers and fear comparison with an individual therapy, of hypoglycemia (57). especially when the problem affects a child It is certainly necessary to further study the (54). phenomenon and work on the popularization of

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