Can J Diabetes xxx (2014) 1e2
Contents lists available at ScienceDirect
Canadian Journal of Diabetes journal homepage: www.canadianjournalofdiabetes.com
Case Report
Intentional Hypoglycemia to Control Bingeing in a Patient with Type 1 Diabetes and Bulimia Nervosa Mandana Moosavi MDCM a, *, Stuart Kreisman MDCM b, Lacresha Hall MD, FAPA b a b
Vancouver Coastal Health, Vancouver, British Columbia, Canada Saint Paul’s Hospital, Vancouver, British Columbia, Canada
a r t i c l e i n f o
a b s t r a c t
Article history: Received 18 January 2014 Received in revised form 28 April 2014 Accepted 30 April 2014 Available online xxx
Most cases of eating disorders associated with type 1 diabetes mellitus are categorized as diabulimia, a disorder of withholding insulin treatment to lose weight through sustained hyperglycemia. In this paper, we report a unique case of a patient with both type 1 diabetes and bulimia nervosa who has an atypical way of controlling her bingeing by keeping her blood sugars low. This pattern of intentionally sustained hypoglycemia has not been previously described in the literature to the best of our knowledge. Knowing various presentations of eating disorders in patients with type 1 diabetes can provide healthcare workers with enhanced ability in recognizing and educating at-risk patients, in the hope of preventing serious hypoglycemia or complications. Furthermore, a patient’s awareness of complications associated with suboptimal control of diabetes, whether by overdosing or underdosing their insulin regimen, might lead to avoidance of disordered eating behaviours. Ó 2014 Canadian Diabetes Association
Keywords: anorexia nervosa diabulimia intentional hypoglycemia type 1 diabetes
r é s u m é Mots clés : anorexie mentale diaboulimie hypoglycémie intentionnellement provoquée diabète de type 1
La plupart des cas de troubles du comportement alimentaire associés au diabète sucré de type 1 sont classifiés dans la catégorie de la diaboulimie, un trouble lié au refus de l’insulinothérapie pour perdre du poids grâce à une hyperglycémie prolongée. Nous exposons dans le présent article un cas unique concernant une patiente souffrant du diabète de type 1 et d’une boulimie mentale qui maîtrise de façon atypique sa frénésie alimentaire en conservant sa glycémie basse. Autant que nous sachions, cette forme d’hypoglycémie intentionnellement prolongée n’a pas encore été décrite dans la littérature. Le fait de connaître les divers tableaux cliniques des troubles de l’alimentation chez les patients souffrant du diabète de type 1 peut permettre aux professionnels de la santé d’améliorer leur aptitude à reconnaître et à éduquer les patients exposés à un risque dans l’espoir de prévenir l’hypoglycémie ou les complications sérieuses. De plus, la sensibilisation des patients aux complications associées à une maîtrise sousoptimale du diabète, soit par le surdosage ou le sous-dosage de leur insuline, permettrait de prévenir les troubles du comportement alimentaire. Ó 2014 Canadian Diabetes Association
Introduction Most cases of eating disorders associated with type 1 diabetes mellitus are categorized as diabulimia (1), a disorder of withholding insulin treatment to lose weight through sustained hyperglycemia (2). There are 3 general categories of eating disorders: bulimia, anorexia and eating disorder not otherwise specified (3). Patient populations more at risk for having eating disorders are mainly female, with higher body mass index and history of dieting or body * Address for correspondence: Mandana Moosavi, MDCM, Division of Endocrinology, St. Paul’s Hospital, 301-1160 Burrard Street, Vancouver, British Columbia V6Z 2E8, Canada. E-mail address: [email protected] 1499-2671/$ e see front matter Ó 2014 Canadian Diabetes Association http://dx.doi.org/10.1016/j.jcjd.2014.04.007
dissatisfaction (4). Eating disorders are also seen more commonly among young patients with diabetes compared with the general population; this increased propensity might be due to the daily focus on carbohydrate intake, weight gain associated with insulin use and ability to manipulate insulin to control weight (4). Diabetes with a concomitant eating disorder has been shown to be associated with worsened metabolic control and increased complications (5). Patients with diabulimia have an abnormal obsession with weight control, and by under-dosing their insulin, thereby maintaining hyperglycemia, they attempt to lose weight (4). This pattern results in an increased frequency of microvascular and macrovascular complications in patients with diabetes (5). Other eating disorders such as restrictive, anorexic behaviour have also been reported for patients with type 1 diabetes (6). Overdosing insulin to
2
M. Moosavi et al. / Can J Diabetes xxx (2014) 1e2
lose weight through inhibition of self-bingeing is an eating disorder pattern that has not been reported for patients with type 1 diabetes. Knowledge of this eating disorder pattern is critical because it is potentially equally dangerous. Case Report A 28-year-old woman with type 1 diabetes diagnosed at age 12 was recently admitted to our eating disorders program. She verbally consented to this report being published. She has struggled with bulimia nervosa for 5 years. Over the last 5 years, she reports a subjective sensation of needing to binge when her glucose levels range from 11 to 14 mmol/L. She tends to binge on a snack; that is followed by a sensation of guilt and then purging. She has a preference for sweet snacks during these episodes. This pattern of eating resulted not only in her feeling sick, but also led to profound fluctuations in her blood glucose ranging from 1.9 to 30 mmol/L levels. She has, therefore, developed a habit of overdosing her insulin to maintain low glycemic levels, aimed at defeating the craving that leads to bingeing; in other words, she overdoses on insulin to acquire a sense of control over her eating patterns. Most patients with type 1 diabetes require, on average, 0.6 to 1 units of insulin per kilogram body weight. Our patient’s body weight ranged between 45 kg and 50 kg, suggesting insulin requirements between 25 and 50 units per day, yet she was using 70 to 80 units of insulin sporadically to provoke hypoglycemia and gain control over her eating disorder. That resulted in increasing frequency, approximately 3 times weekly, of dangerously low blood sugars, generally between 1.9 and 2.5 mmol/L in the past year. She tests her blood sugars fasting, before meals and before bedtime every day. Fortunately, she has not yet had any episodes requiring assistance; however, hypoglycemia unawareness has developed, and for that reason, she does not drive a car. To complicate matters further, during the past 5 years, her eating disorder has not been under control and her bingeing has resulted in long periods of untreated hyperglycemia; moreover, her diabetes control has been poor, with glycated hemoglobin ranging from 9.8% to 10.6%. Unfortunately, peripheral neuropathy and gastroparesis already have developed despite her young age. Her eating disorder resulted in her admission to the hospital for 5 weeks, with multiple setbacks, including hospital-associated infections and fluctuations in her blood glucose and weight. While on the eating disorder ward, she received cognitive behavioural therapy as well as eating disorder counselling. By participating in group discussions and in individual motivational meetings with dietitians, psychiatrists and nutritionists, she gained more insight into her eating disorder. At the time of her discharge, she had a reasonable understanding of her diabetes control and of ways by which she can maintain a stable weight by eating a balanced diet. She will be followed up as an outpatient by her endocrinologist and psychiatrist. Her family also received counselling and will be participating in her outpatient care. Discussion Hyperglycemia worsening binge cravings in type 1 diabetes patients with bulimia nervosa has not been previously described; thus, its mechanism is unknown. Normally, once blood glucose falls, there is stimulation of counter-regulatory hormones such as cortisol, growth hormone and epinephrine and increased hunger (7). The opposite, seen here, is difficult to interpret. One
possible explanation could be that the patient’s craving for sweets increases as her blood sugars remain high due to insulin deficiency over a longer period. Lack of insulin inhibits glucose uptake at a cellular level, leading to a state of starvation, as seen with children who have undiagnosed type 1 diabetes, who may describe months of polyphagia and cravings for sweets. Another potential explanation may relate to her psychiatric disorder and a sense of loss of control when her blood sugars are high; perhaps by bingeing and purging, she regains a sense of empowerment. We have reported the case of a patient with type 1 diabetes who intentionally overdoses her insulin to prevent hyperglycemiainduced binge and purge cravings. It is well known that eating disorder in patients with type 1 diabetes leads to deterioration in diabetes-related outcomes and the patient’s quality of life, increasing hospital admissions and healthcare costs (8). It is, therefore, essential to recognize when patients with diabetes demonstrate early signs of any abnormal eating pattern. Even mild eating problems, if ignored, can lead to serious eating disorder with its associated medical complications. Our case is an atypical pattern of eating disorder in a young patient with type 1 diabetes that led to prolonged hospitalization and increased diabetes-related complications. We aim to highlight the twin dangers of hypoglycemia and poor metabolic control in type 1 diabetes patients with eating disorder and the urgency of recognizing various patterns of eating disorder in these patients. The goal is to prevent complications and to develop a sustainable approach to educate such patients and healthcare workers in the management of these coexisting chronic diseases. Acknowledgements We would like to thank Saint Paul’s Hospital and many of the healthcare staff at the Eating Disorders Clinic. Author Contributions Dr. Mandana Moosavi researched data and wrote the manuscript. Dr. Stuart Kreisman edited and reviewed the manuscript. Dr. Lacresha Hall added data and edited the manuscript. Author Disclosures The authors have no conflicts of interest to disclose. References 1. Kelly SD, Howe CJ, Hendler JP, et al. Disordered eating behaviors in youth with type 1 diabetes. Diabetes Educator 2005;31:572. 2. Takii M, Uchigata Y, Nozaki T, et al. Classification of type 1 diabetic females with bulimia nervosa into subgroups according to purging behavior. Diabetes Care 2002;25:1571e5. 3. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th edn. Arlington: American Psychiatric Publishing, 2013. 4. Young V, Eiser C, Johnson B, et al. Problems in adolescents with type 1 diabetes: A systemic review with meta analysis. Diabet Med 2013;30:189e98. 5. Larrañaga A, Docet MF, Garcia-Mayor RV. Disordered eating behaviors in type 1 diabetic patients. World J Diabetes 2011;2:189e95. 6. Rodin GM, Johnson LE, Garfinkel PE, et al. Eating disorders in female adolescents with insulin dependent diabetes. Int Psychiatry Med 1986-1987;16:49e57. 7. Westerberg DP. Diabetic ketoacidosis: Evaluation and treatment. Am Fam Phys 2013;87:337e46. 8. Powers PS, Malone JI, Coovert DL, et al. Insulin-dependent diabetes mellitus and eating disorders: A prevalence study. Comprehens Psychiatry 1990;3:205e10.
Contents lists available at ScienceDirect
Canadian Journal of Diabetes journal homepage: www.canadianjournalofdiabetes.com
Case Report
Intentional Hypoglycemia to Control Bingeing in a Patient with Type 1 Diabetes and Bulimia Nervosa Mandana Moosavi MDCM a, *, Stuart Kreisman MDCM b, Lacresha Hall MD, FAPA b a b
Vancouver Coastal Health, Vancouver, British Columbia, Canada Saint Paul’s Hospital, Vancouver, British Columbia, Canada
a r t i c l e i n f o
a b s t r a c t
Article history: Received 18 January 2014 Received in revised form 28 April 2014 Accepted 30 April 2014 Available online xxx
Most cases of eating disorders associated with type 1 diabetes mellitus are categorized as diabulimia, a disorder of withholding insulin treatment to lose weight through sustained hyperglycemia. In this paper, we report a unique case of a patient with both type 1 diabetes and bulimia nervosa who has an atypical way of controlling her bingeing by keeping her blood sugars low. This pattern of intentionally sustained hypoglycemia has not been previously described in the literature to the best of our knowledge. Knowing various presentations of eating disorders in patients with type 1 diabetes can provide healthcare workers with enhanced ability in recognizing and educating at-risk patients, in the hope of preventing serious hypoglycemia or complications. Furthermore, a patient’s awareness of complications associated with suboptimal control of diabetes, whether by overdosing or underdosing their insulin regimen, might lead to avoidance of disordered eating behaviours. Ó 2014 Canadian Diabetes Association
Keywords: anorexia nervosa diabulimia intentional hypoglycemia type 1 diabetes
r é s u m é Mots clés : anorexie mentale diaboulimie hypoglycémie intentionnellement provoquée diabète de type 1
La plupart des cas de troubles du comportement alimentaire associés au diabète sucré de type 1 sont classifiés dans la catégorie de la diaboulimie, un trouble lié au refus de l’insulinothérapie pour perdre du poids grâce à une hyperglycémie prolongée. Nous exposons dans le présent article un cas unique concernant une patiente souffrant du diabète de type 1 et d’une boulimie mentale qui maîtrise de façon atypique sa frénésie alimentaire en conservant sa glycémie basse. Autant que nous sachions, cette forme d’hypoglycémie intentionnellement prolongée n’a pas encore été décrite dans la littérature. Le fait de connaître les divers tableaux cliniques des troubles de l’alimentation chez les patients souffrant du diabète de type 1 peut permettre aux professionnels de la santé d’améliorer leur aptitude à reconnaître et à éduquer les patients exposés à un risque dans l’espoir de prévenir l’hypoglycémie ou les complications sérieuses. De plus, la sensibilisation des patients aux complications associées à une maîtrise sousoptimale du diabète, soit par le surdosage ou le sous-dosage de leur insuline, permettrait de prévenir les troubles du comportement alimentaire. Ó 2014 Canadian Diabetes Association
Introduction Most cases of eating disorders associated with type 1 diabetes mellitus are categorized as diabulimia (1), a disorder of withholding insulin treatment to lose weight through sustained hyperglycemia (2). There are 3 general categories of eating disorders: bulimia, anorexia and eating disorder not otherwise specified (3). Patient populations more at risk for having eating disorders are mainly female, with higher body mass index and history of dieting or body * Address for correspondence: Mandana Moosavi, MDCM, Division of Endocrinology, St. Paul’s Hospital, 301-1160 Burrard Street, Vancouver, British Columbia V6Z 2E8, Canada. E-mail address: [email protected] 1499-2671/$ e see front matter Ó 2014 Canadian Diabetes Association http://dx.doi.org/10.1016/j.jcjd.2014.04.007
dissatisfaction (4). Eating disorders are also seen more commonly among young patients with diabetes compared with the general population; this increased propensity might be due to the daily focus on carbohydrate intake, weight gain associated with insulin use and ability to manipulate insulin to control weight (4). Diabetes with a concomitant eating disorder has been shown to be associated with worsened metabolic control and increased complications (5). Patients with diabulimia have an abnormal obsession with weight control, and by under-dosing their insulin, thereby maintaining hyperglycemia, they attempt to lose weight (4). This pattern results in an increased frequency of microvascular and macrovascular complications in patients with diabetes (5). Other eating disorders such as restrictive, anorexic behaviour have also been reported for patients with type 1 diabetes (6). Overdosing insulin to
2
M. Moosavi et al. / Can J Diabetes xxx (2014) 1e2
lose weight through inhibition of self-bingeing is an eating disorder pattern that has not been reported for patients with type 1 diabetes. Knowledge of this eating disorder pattern is critical because it is potentially equally dangerous. Case Report A 28-year-old woman with type 1 diabetes diagnosed at age 12 was recently admitted to our eating disorders program. She verbally consented to this report being published. She has struggled with bulimia nervosa for 5 years. Over the last 5 years, she reports a subjective sensation of needing to binge when her glucose levels range from 11 to 14 mmol/L. She tends to binge on a snack; that is followed by a sensation of guilt and then purging. She has a preference for sweet snacks during these episodes. This pattern of eating resulted not only in her feeling sick, but also led to profound fluctuations in her blood glucose ranging from 1.9 to 30 mmol/L levels. She has, therefore, developed a habit of overdosing her insulin to maintain low glycemic levels, aimed at defeating the craving that leads to bingeing; in other words, she overdoses on insulin to acquire a sense of control over her eating patterns. Most patients with type 1 diabetes require, on average, 0.6 to 1 units of insulin per kilogram body weight. Our patient’s body weight ranged between 45 kg and 50 kg, suggesting insulin requirements between 25 and 50 units per day, yet she was using 70 to 80 units of insulin sporadically to provoke hypoglycemia and gain control over her eating disorder. That resulted in increasing frequency, approximately 3 times weekly, of dangerously low blood sugars, generally between 1.9 and 2.5 mmol/L in the past year. She tests her blood sugars fasting, before meals and before bedtime every day. Fortunately, she has not yet had any episodes requiring assistance; however, hypoglycemia unawareness has developed, and for that reason, she does not drive a car. To complicate matters further, during the past 5 years, her eating disorder has not been under control and her bingeing has resulted in long periods of untreated hyperglycemia; moreover, her diabetes control has been poor, with glycated hemoglobin ranging from 9.8% to 10.6%. Unfortunately, peripheral neuropathy and gastroparesis already have developed despite her young age. Her eating disorder resulted in her admission to the hospital for 5 weeks, with multiple setbacks, including hospital-associated infections and fluctuations in her blood glucose and weight. While on the eating disorder ward, she received cognitive behavioural therapy as well as eating disorder counselling. By participating in group discussions and in individual motivational meetings with dietitians, psychiatrists and nutritionists, she gained more insight into her eating disorder. At the time of her discharge, she had a reasonable understanding of her diabetes control and of ways by which she can maintain a stable weight by eating a balanced diet. She will be followed up as an outpatient by her endocrinologist and psychiatrist. Her family also received counselling and will be participating in her outpatient care. Discussion Hyperglycemia worsening binge cravings in type 1 diabetes patients with bulimia nervosa has not been previously described; thus, its mechanism is unknown. Normally, once blood glucose falls, there is stimulation of counter-regulatory hormones such as cortisol, growth hormone and epinephrine and increased hunger (7). The opposite, seen here, is difficult to interpret. One
possible explanation could be that the patient’s craving for sweets increases as her blood sugars remain high due to insulin deficiency over a longer period. Lack of insulin inhibits glucose uptake at a cellular level, leading to a state of starvation, as seen with children who have undiagnosed type 1 diabetes, who may describe months of polyphagia and cravings for sweets. Another potential explanation may relate to her psychiatric disorder and a sense of loss of control when her blood sugars are high; perhaps by bingeing and purging, she regains a sense of empowerment. We have reported the case of a patient with type 1 diabetes who intentionally overdoses her insulin to prevent hyperglycemiainduced binge and purge cravings. It is well known that eating disorder in patients with type 1 diabetes leads to deterioration in diabetes-related outcomes and the patient’s quality of life, increasing hospital admissions and healthcare costs (8). It is, therefore, essential to recognize when patients with diabetes demonstrate early signs of any abnormal eating pattern. Even mild eating problems, if ignored, can lead to serious eating disorder with its associated medical complications. Our case is an atypical pattern of eating disorder in a young patient with type 1 diabetes that led to prolonged hospitalization and increased diabetes-related complications. We aim to highlight the twin dangers of hypoglycemia and poor metabolic control in type 1 diabetes patients with eating disorder and the urgency of recognizing various patterns of eating disorder in these patients. The goal is to prevent complications and to develop a sustainable approach to educate such patients and healthcare workers in the management of these coexisting chronic diseases. Acknowledgements We would like to thank Saint Paul’s Hospital and many of the healthcare staff at the Eating Disorders Clinic. Author Contributions Dr. Mandana Moosavi researched data and wrote the manuscript. Dr. Stuart Kreisman edited and reviewed the manuscript. Dr. Lacresha Hall added data and edited the manuscript. Author Disclosures The authors have no conflicts of interest to disclose. References 1. Kelly SD, Howe CJ, Hendler JP, et al. Disordered eating behaviors in youth with type 1 diabetes. Diabetes Educator 2005;31:572. 2. Takii M, Uchigata Y, Nozaki T, et al. Classification of type 1 diabetic females with bulimia nervosa into subgroups according to purging behavior. Diabetes Care 2002;25:1571e5. 3. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th edn. Arlington: American Psychiatric Publishing, 2013. 4. Young V, Eiser C, Johnson B, et al. Problems in adolescents with type 1 diabetes: A systemic review with meta analysis. Diabet Med 2013;30:189e98. 5. Larrañaga A, Docet MF, Garcia-Mayor RV. Disordered eating behaviors in type 1 diabetic patients. World J Diabetes 2011;2:189e95. 6. Rodin GM, Johnson LE, Garfinkel PE, et al. Eating disorders in female adolescents with insulin dependent diabetes. Int Psychiatry Med 1986-1987;16:49e57. 7. Westerberg DP. Diabetic ketoacidosis: Evaluation and treatment. Am Fam Phys 2013;87:337e46. 8. Powers PS, Malone JI, Coovert DL, et al. Insulin-dependent diabetes mellitus and eating disorders: A prevalence study. Comprehens Psychiatry 1990;3:205e10.
