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Diabulimia Position Statement Mar 2017.Pdf POSITION STATEMENT Diabulimia Last reviewed: March 2017 KEY POINTS: • Diabulimia is not a recognised medical or psychiatric term but describes the practice of reducing or omitting insulin in order to lose weight • It has been suggested that 40% of women with Type 1 diabetes may omit or reduce insulin to lose weight and 11% of adolescent boys • Diabulimia is associated with increased morbidity and mortality • Awareness of the signs and consequences of diabulimia must be raised with friends and family of people with Type 1, and with healthcare professionals • Appropriate support and treatment must be available to people with diabulimia and occurs over a long period of time, it is Introduction classed as diabulimia. Diabulimia is not a recognised medical or Current situation psychiatric condition but a term used to describe a ‘disordered eating behaviour’ in the It is difficult to estimate the number of people practice of reducing or omitting insulin in order with diabulimia. Published prevelance data are to lose weight. While not formally recognised as inconsistent due to the different methodology a mental health condition in it’s own right, the used, and so findings should be used with Diagnostic Statistical Manual of Mental caution. However, estimates of insulin omission Disorders (DSM-5) (1) considers that insulin have been reported in up to 40% of people with omission in order to lose weight is a clinical diabetes (4). feature of anorexia and bulimia. Similarly, Diabulimia has also been recognised in the most It is not just women that can be affected by recent NICE guidance for eating disorders diabulimia. Research also shows that men with (currently in press)(2). Research has found Type 1 diabetes have a ‘higher drive for diabulimia to be the term that people who thinness’, a key driving factor in the reduce or omit insulin in this way like to use to development of an eating disorder, than their describe the practice(3). Consequently the non-diabetic counterparts (5), making them more term “diabulimia” will be used in this susceptible to diabulimia. A recent study from position statement. Germany suggests that 11.2% of boys between 11-19 omit insulin to lose weight(6) There are a number of reasons why insulin may be reduced or omitted, such as fear of hypos or The recommended management of Type 1 underestimating carbohydrate counting. diabetes can make an individual more vulnerable However, when this is related to weight control to an eating disorder. The following have been listed as diabetes-specific contributory factors • Must offer sensitive support to people that can lead to eating disorders in people with with diabetes and avoid comments or Type 1 diabetes: procedures that may trigger insulin omission (eg unnecessary monitoring of • Attention to food labels weight), see www.dwed.org.uk. • Attention to weight • Bingeing following hypoglycaemia In addition, there are specific calls to action in • Constant awareness of numbers England and Wales: • Parental attitude towards Type 1 diabetes • Shame over management England • Negative relationships with healthcare • The Mental Health Taskforce professionals recommendation to increase access to • Difficulty losing weight due to insulin therapy evidence-based psychological therapies for people who are living with long-term It is unlikely that any of these factors exist by physical health conditions must be themselves and diabulimia usually develops from implemented. The choice of therapy a complex combination of biological, offered should consider evidence for psychological and social difficulties. effectiveness and patient choice Consequences of diabulimia • As part of this, NHS England and Health Education England must ensure that the Diabulimia is associated with an increase in right staff and services are available to (7-9) retinopathy, nephropathy and foot problems , identify, support and treat people with and the duration of severe insulin omission is the diabetes who are misusing insulin to factor most closely associated with the control their weight within the development of retinopathy and nephropathy (9). multidisciplinary diabetes team. Diabetes UK Wales calls to action The Welsh Government’s Together for Health: A Diabetes Delivery Plan(10) states that: Diabetes UK calls for the following action across ‘It has been estimated that 41% of people with the UK to improve recognition and management diabetes have poor psychological well-being, of diabulimia, and so improve patient outcomes. with eating disorders as well as depression and anxiety as presenting difficulties. Assessment of • Psychological factors should always be psychological difficulties that may pose a barrier considered, assessed and excluded in all to effective self-care and medical management episodes of DKA of diabetes is essential. Health boards must • Sufficient time, resources and training ensure sufficient psychological input into the must be in place to enable diabetes management of patients in line with national healthcare professionals to identify and standards. All members of the care team should support people with diabulimia effectively be supported to provide an element of psychological support, in line with the pyramid of Healthcare professionals across the UK psychological need, to target clinical psychologist support at those with the greatest • Must be aware of the possible signs of need.’ diabulimia (see below) Diabetes UK Cymru is working with Welsh Government and other stakeholders to monitor • Must consider diabulimia as a potential implementation of the plan. reason for recurrent DKA • Must refer people with diabulimia to appropriate specialist services without delay . A charity registered in England and Wales (215199) and in Scotland (SC039136). © Diabetes UK 2016 psychological services that can provide the Recommendations integrated support that people with diabulimia need. Early intervention and referral is crucial. This section sets out Diabetes UK’s An example of good practice is the service at recommedations in relation to diabulimia. These the South London and Maudsley NHS are around awareness and treatment of the Foundation Trust. Professionals at the Trust condition. state that treatment for diabulimia is complex and requires good physical and psychological Awareness care. Healthcare professionals, family and friends of Psychological therapy relies on a brain which people with Type 1 diabetes should be aware of can learn and reflect so is less effective if brain the signs that could indicate diabulimia. These function is compromised by poor diabetic (11-12) can include : control or a low BMI. Likewise if diabetes • Weight loss/fluctuation in weight professionals do not consider emotions around • High HbA1c food and body shape then diabetes education • Recurrent DKA/admission to hospital for will be ineffective. hyperglycaemia • Regular symptoms of high blood glucose The Trust offer a service for people with levels diabulimia where psychiatrists and diabetes • Early onset of diabetes complications clinicians work in teams together - bridging the • Secrecy over or fear of injecting gap between physical and psychological care. • Reluctance to be weighed The service provides inpatient, day patient and • Not attending diabetes appointments outpatient care and offers people with diabulimia • Lack of blood glucose monitoring/ an opportunity to explore their difficulties and reluctance to self monitor gain control over their eating disorder through • Depression, anxiety or other one-to-one, group and family care. psychological disturbance Pubertal delay, amenorrhea or irregular • Research menses • Changes in appetite Given the difficulites in establishing the number • An encyclopaedic knowledge of nutritional composition of foods of people with diabulimia, there is a need for • Fear of gaining weight more research into effective screening • Distorted body image instruments. This is applicable to both men and • Withdrawal from ususal activities women, but is particularly pertinent to men, as numbers of men affected are very difficult to It is important to note of course that there are establish. There must also be further research other resons for these signs or behaviours and into effective treatments. they do not necessarily always indicate diabulimia. However, healthcare professionals, family and friends should be aware that Conclusion diabulimia could be a cause. Treatment Diabulimia is a serious condition which can Standard treatments for eating disorders are not result in increased and earlier compications of usually appropriate for cases of diabulimia. diabetes and reduce both life expectancy and Treatment for eating disorders tend to involve quality of life. Currently there is a lack of removing the focus on food, which is of course awareness of the condition amongst family and contrary to recommended advice for friends of people with Type 1 diabetes, and also management of Type 1diabetes. Instead, better amongst healthcare profesionals who do not access is needed to diabetes specialist necessarily consider it as a cause for recurrent DKA or persistant hyperglycaemia. Added to . A charity registered in England and Wales (215199) and in Scotland (SC039136). © Diabetes UK 2016 this, there is extremely poor access to the 7035442 specialist care that is vital to support people with 7. Rodin G. et. al (2002) Eating disorders in diabulimia in the most appropriate way. Diabetes young women with type 1 diabetes. J. UK recommends that both awareness of the Psychosom Res. 53(4):943-9
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