WHAT YOU NEED TO KNOW ABOUT ED-DMT1, “DIABULIMIA”
written by: Margherita Mascolo, MD, CEDS;Lyn Goldring, BN, RN, CEDRN
At Alsana, we believe that all individuals with an eating disorder deserve holistic care adapted to their unique needs. For individuals with co-occurring eating disorders and diabetes mellitus type I, a safe, inviting environment with professionals who specialize in both diagnoses is vital for a full recovery. Alsana’s program meets these clients where they are on their road to recovery. We walk side-by-side with clients as they work to heal their bodies, uncover the roots of the eating disorder, and rediscover their true selves.
What is Diabulimia?
“Diabulimia” is the colloquial name for the dual diagnosis of a person with eating disorders and type 1 diabetes who manipulates their insulin doses in an effort to control their weight. More formally, these behaviors are referred to as the dual diagnosis of “eating disorder-diabetes Mellitus type 1,” or “ED-DMT1.”
ED-DMT1 is not an officially-recognized diagnosis in the Diagnostic and Statistical Manual of Mental Disorders (DSM-V). Rather, it is a broad term to describe someone with both an eating disorder and diabetes. Based on a person’s eating disorder behaviors, they may be diagnosed with anorexia nervosa, bulimia nervosa, or other specified feeding and eating disorder (OSFED) in addition to their diabetes diagnosis.
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Warning Signs of Diabulimia (ED-DMT1)
- Fear of taking insulin and insulin restriction
- Irregular eating patterns
- Avoidant of sweets and fats
- Gravitate towards “safe foods”
- Avoidant of meals
- Binges + feelings of guilt and fear of weight gain
- Limiting or omitting insulin
- Avoidant of doctor’s appointments
- Untruthful to doctors and family about blood glucose values
- Frequent visits to the emergency room for diabetic ketoacidosis (DKA)
- May voice body image concerns or body dissatisfaction
- May display intense obsession about weight
- Secrecy and/or non-truths about diabetic management
Symptoms of Diabulimia (ED-DMT1)
- Early-onset of diabetic medical complications: frequent infections (UTI, yeast, skin, Staph, etc.), deteriorating vision, gastroparesis, neuropathy, renal disease, and cardiovascular complications
- Consistently high hemoglobin A1c levels (range of blood sugars over a 3-month period)
- Frequently omit insulin at mealtimes despite multiple episodes of DKA
- Frequent urination
- Excessive thirst
- Excessive hunger
- Overlapping symptoms of eating disordered behaviors beyond insulin omission: restriction, binging, purging, use of laxatives, and over-exercising
- Extreme lethargy
- Can occur in clients with “normal” body weight, clients with larger bodies, and in clients with lower-weight bodies (note: prior to the diagnosis of DMT1, it is common to lose weight)
When an individual is diagnosed with diabetes, there is an immediate and constant focus on controlling “numbers.” As a result, there is regular worry about their blood sugar numbers, carb counting, hemoglobin A1c levels, and insulin dosing–among others.
This focus on numbers and control can make it easy to fall into eating disorder behaviors, which are also based on numbers and control.
Eating Disorders and Type-2 Diabetes
Type-2 diabetics also have an emphasis on the food they eat, are encouraged to count and restrict carbohydrates, keep their blood sugar levels down, and have an intense focus on numbers such as hemoglobin A1c. This focus on numbers and restrictive eating can lead to eating disorders such as anorexia, bulimia, binge eating disorder, or other specified feeding or eating disorder (OSFED), even if the person has not been prescribed insulin.
Most individuals with type-2 diabetes still produce insulin. However, their body develops insulin resistance, which means that it isn’t able to absorb and utilize insulin effectively. Over their disease course, type-2 diabetics may eventually be prescribed insulin to help their body process ingested carbohydrates. If they begin to manipulate their insulin dosage to influence weight, they may be diagnosed with a co-occurring eating disorder and require treatment for both conditions.
ED-DMT1 Health Consequences
The health consequences of co-occurring eating disorders and diabetes are serious and can be life-threatening. The risk of death for ED-DMT1 is 17x more likely than type-1 diabetes alone, and 7x more likely than anorexia alone*.
Clients with ED-DMT1 may develop diabetic ketoacidosis (DKA), which occurs when the lack of insulin (common in clients with a new diagnosis of diabetes or in a client who is underdosing their insulin) prevents the body from utilizing glucose for fuel. Instead, the body breaks down fat in the liver and turns it into ketones. Ketones are acidic and cause a lowering of blood pH resulting in a state of acidosis. DKA typically presents with high blood glucose levels (over 250 mg/dL, although it’s usually much higher), acidosis, and ketones in the urine. Without proper treatment, DKA can result in a coma or death.
Other common health complications of ED-DMT1 include:
- Hyperglycemia (high blood sugar)
- Electrolyte imbalance
- Menstrual abnormalities in females
- Peripheral neuropathy (pain, weakness, or numbness in the extremities, such as hands, feet, arms, and legs)
- Impaired vision that can lead to blindness (retinopathy)
- Kidney disease that can lead to kidney failure (nephropathy)
- Heart disease and cardiovascular complications
Alsana offers enhanced programming based on our Adaptive Care Model that supports our integrative approach to care, assisting clients in our five dimensions as they journey toward wellness.
- On-site nursing 24/7 at all residential programs
- All staff at ED-DMT1 programs are specially trained in treating co-occurring eating disorders and diabetes
- Daily movement program
- Hands-on kitchen skills training
- Treatment of co-occurring conditions such as anxiety, depression, trauma, and substance abuse
- Focus on underlying issues and the functional aspects of the eating disorder
- Management of medical complications associated with diabetes
Working with the Diabulimia Helpline
At Alsana, we provide evidence-based treatment for all our clients. We believe one of the foundational ways to provide such care is through staff education and training. To support this effort, Alsana provides all disciplines with internal training by our Chief Medical Officer, Chief Nursing Officer, Chief Clinical Officer, Vice President of Nutrition, and Vice President of Movement. In addition, Alsana has partnered with the Diabulimia Helpline to provide all our service lines supplemental training specific to eating disorders and DMT1. Our training spans from the admissions team to each discipline in the clinical team so that from the moment the client reaches out to Alsana, they are welcomed by staff familiar with their disorders and sensitive to their needs. Once they are admitted to our facility, each staff member from the direct care to the physician are trained and well-versed in the care and treatment of ED-DMT1.
If you have a client exhibiting signs of diabulimia, call us today or visit alsana.com/livechat to speak with one of our mental health professionals. We will discuss the level of care that is appropriate for your client and whether or not Alsana could be the healing place needed for your client. We look forward to hearing from you!
*Mortality in concurrent type 1 diabetes and anorexia nervosa. Nielsen S, Emborg C, Mølbak AG. Diabetes Care. 2002 Feb; 25(2):309-12.
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