Thursday, August 2, 2007 - 4:25pm

By John Messmer, MD

Perhaps you have heard of bulimia. It gets into the news from time to time when some celebrity is found to have her weight dropping and rising. It is related to anorexia but unlike anorexia, those with bulimia tend to be at a normal or slightly above normal weight.

Basic bulimia and diabetic bulimics

Bulimia is a woman's illness seen in up to 4 percent of younger women and is characterized episodes of uncontrolled binge eating--eating excessively in short spans of time. Because of concern about gaining weight, the overeating is followed by purging with laxatives, the use of diuretics to remove water weight, or inducing vomiting. In some cases, fasting and excessive exercise are also included. There is a feeling of lack of control over the episodes and much guilt.1

Bulimic women who have type 1 diabetes have discovered another way to manage their weight in association with binge eating. They withhold insulin. The term "diabulimia" has been used to describe this type of bulimic although the name is not official.

Diabetics and insulin

Type 1 diabetes is characterized by the inability to make insulin, which is needed to get the sugar from our food into our body's cells. Sugar in our diets comes from sweet foods and from starches in grain products, fruit, and vegetables. Starches are made from many sugar molecules attached to one another. Enzymes digest the starches, and we absorb the resulting sugars into our blood.

When we eat, our pancreas begins to release insulin. Insulin is needed to get the sugar out of our blood and into our cells where it is broken down for energy or stored for later. Excess sugar is stored as glycogen, a form of starch, or changed into fat and stored as body fat. Eat too much, and we get fatter. If there is no insulin available, the sugar cannot enter the cells to be stored or to be used for energy. Instead, it passes out in the urine.

How bulimic diabetics curb weight gain

Bulimic diabetics have discovered that if they give themselves just enough insulin to keep the body running at minimum energy, they can eat more without gaining weight; and if blood sugar is kept high enough, they lose weight. Bulimia is a more common problem in diabetic girls than in non-diabetics.2

Diabulimia and short-term and long-term health risks

Bulimia has certain health risks, including tooth enamel injury and esophageal injury from vomiting, heart rhythm problems from electrolyte disturbances, and intestinal disturbances from vomiting and purging. For a diabetic, the potential complications include these and all the problems of poorly controlled diabetes.

In the short term, excessively high blood sugar dehydrates the body. If it becomes too high, it can lead to coma. Excess sugar is converted to acids which interfere with proper functioning of the brain and heart. Potassium levels drop, compounding heart rhythm risks which can cause death.

Some diabetics have learned to withhold just enough insulin to avoid these short-term risks, but long-term poorly controlled diabetes wreaks havoc on every body system. It has been demonstrated in the Diabetes Control and Complications Trial (DCCT) that diabetics who maintain blood sugar close to normal have far fewer heart problems and less nerve damage than those whose blood sugars run higher.3,4 A large study in the United Kingdom showed that tight glucose control reduces the risk of blindness due to diabetic retinal damage.5 It is clear that diabetics who do not take enough insulin risk early heart disease, strokes, blindness, painful nerve damage, and kidney failure, and may die 15 years sooner than those who control the diabetes well.6

Bulimia: the importance of treatment

Bulimia is treatable, but it can be difficult. Our society glamorizes thin bodies. Overcoming bulimia takes skilled counselors and a patient who can learn to put health ahead of thinness and give up some of the obsessive behaviors associated with bulimia. For diabetic bulimics, the short- and long-term risks are great.

[1] http://www.nimh.nih.gov/publicat/eatingdisorders.cfm accessed July 15, 2007.

[2] Colton P. et al, Disturbed Eating Behavior and Eating Disorders in Preteen and Early Teenage Girls with Type 1 Diabetes. Diabetes Care 27: 1654-1659, 2004.

[3] Venkat Narayan, KM, Glycemic Control and Cardiovascular Disease in Patients with Diabetes. Clinical Diabetes 24:88-89, 2006.

[4] Factors in development of diabetic neuropathy. Baseline analysis of neuropathy in feasibility phase of Diabetes Control and Complications Trial (DCCT). The DCCT Research Group. Diabetes, Vol 37, Issue 4 476-481.

[5] Diabetic Retinopathy: a position statement. Clinical Diabetes 19:29-32, 2001.

[6] Kasper, D, et al, Harrison's Principles of Internal Medicine, 16th ed. McGraw-Hill, 2005.