Request for new concept - Eating disorder co-occurrent with diabetes mellitus

user-253b9 , in reading the reference you listed, a key sentence grabbed me ("ED-DMT1 is a relatively new term and the link between type 1 diabetes and eating disorders is not yet recognized as a medical or psychiatric condition.").  In searching Google scholar and pubmed, there are multiple references to this practice of withholding insulin to effect weight loss in diabetic patients; however,  because diabulemia may refer to multiple types of eating disorders, not just withholding of insulin,  the question we must ask is whether this type of eating disorder is unique enough in its mechanism to warrant a combine concept as opposed to suggesting that two terms be used, to specify the nature of the eating disorder in the presence of DM1.

user-253b9 My personal sense is that it should be sufficient to include both terms separately on the problem list and not create an additional term for the co-occurrence of the two disorders.   However, before responding,  I asked a colleague with eating disorders expertise (Joel Yager, who chaired the prior American Psychiatric Association Practice Guidelines groups for Eating Disorders).  He notes that "Some people use the term "diabulimia" to refer to people w DM who "purge" by playing around w their insulin, usually becoming glycosuric."  However, he said that he doesn't think the term adds particular value and agreed that it's probably better not to add this term.  

When I clicked on the reference you gave, I just got a 404 page load error and no content.  So I don't know if offered a better rationale or not. 

As Jim Case points out, diabulimia may refer to multiple types of eating disorders.  Consequently, I would also point out that I think the term is potentially misleading by implying that it's a link between diabetes and bulimia when it's often occurring in people with type 1 diabetes and anorexia nervosa (at least as I understand it).

Plus, at least one site (https://www.nationaleatingdisorders.org/diabulimia-5) claims the term is media-inspired, which is a bit disconcerting. 

I don't think there is any unique mechanistic or psychological link between the presence of diabetes and the development of an eating disorder.  Most people who have Type 1 diabetes don't develop an eating disorder despite the need to adhere to specific dietary requirements.  I'm not even sure how frequently people with co-occurring eating disorder and diabetes engage in dangerous adjustments of insulin in an effort to foster weight loss. 

Finally, I'm not sure what SNOMED rules are in terms of having "new" names to represent a fusion of comorbidities.  But it seems like a rather bad precedent to set without clearcut etiological or other links or clearcut clinical implications for adding the term.

I agree with the thoughtful comment of Laura on this terminology policy.
Darrel Regier

@ Paul Amos, the link you have shared is not working (http://www.wearediabetes.org/diabulimia.php)

Is it possible for you to share a link which is working?

In ICD 10 Clinical descriptions and diagnostic guidelines, chapter F50.2 (Bulimia nervosa) under Diagnostic guidelines section b, it is mentioned that when bulimia occurs in diabetic patients they may choose to neglect their insulin treatment. 

Therefor ICD 10 has already considered this fact under a diagnosis of Bulimia Nervosa which itself is a very broad category.

Considering this fact, a new concept such as diabulimia can be a possibility if we want to differentiate patients with Diabetes and Bullimia who are manipulating insulin dose to control weight from other Bulimia Nervosa patients.

To be more specific, a Parent Child relationship between Bulimia Nervosa and Diabulimia can be considered.

This is obviously a complex topic.  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2827531/ gives a very thoughtful discussion of multiple aspects of disordered eating behaviors in diabetic patients and insulin restriction appears to be fairly common among individuals with diabetes and any sort of disordered eating behavior: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5796840/.

In DSM-5, the discussion of Anorexia Nervosa (under Associated Features Supporting Diagnosis), specifically notes that "Individuals with diabetes mellitus may omit or reduce insulin doses in order to minimize carbohydrate metabolism."  Although the term "diabulimia" isn't used per se, it's clear that the phenomenon of manipulating insulin doses to control weight is not unique to bulimia nervosa.  (It's also not surprising that the term "diabulimia" isn't used in DSM-5 because it's not a conventional medical term.) 

From the standpoint of clinical care and clarity of communications, it would seem to me that it would be much better to have a SNOMED term for intentional restriction of insulin doses, if one doesn't exist already.  For individuals with an eating disorder, type 1 diabetes and intentional insulin restriction, all three terms could be used.  For those with just an eating disorder and type 1 diabetes (but without insulin restriction), those two terms could be used. 

Intentional restriction of insulin doses may also apply to individuals who are not taking insulin doses for other reasons (e.g., cost) totally independent of eating pathology.  This would also be important to be able to note clinically given the long-term health consequences of insulin restriction regardless of the underlying motivation.

In my opinion, this approach would give much greater clarity and information to clinicians and researchers than inserting a confusing, poorly defined and media-fueled term such as diabulimia into SNOMED.

@Laura. Thanks for your reply and explaining it in much detail. 

There are certain obvious differences between ICD 10 and DSM V. Hopefully ICD 11 and DSM V will have more similarities than differences.

According to ICD - F50.2 ICD 10 

" Patients attempts to counteract the "fattening" effects of food by one or more of the following : Self Induced vomiting, purgative abuse, alternating periods of starvation, use of drugs such as appetite suppressants, thyroid preparations or diuretics. When Bulimia occur in diabetic patients they may choose to neglect their insulin treatment."

As you recommended a new term - Intentional restriction of Insulin dose.

So a possible hierarchy in my view could be as follows provided the organisation decide to include these new terms.

(Parent)

Intentional restriction of Insulin [A broad term, it can be because of many reasons]

(Children)

• Intentional restriction of Insulin for the purpose of weight loss  
• Intentional restriction of Insulin due to Cost.
• Intentional restriction of Insulin due to.......

Parent

Eating Disorder(disorder)

Children

• Eating Disorder co-occurent with Intentional restriction of Insulin for the purpose of weight loss

Parent

Anorexia Nervosa (disorder)

Children

• Anorexia Nervosa co-occurent with Intentional restriction of Insulin for the purpose of weight loss

Parent

Bulimia Nervosa (disorder)

Children

• Bulimia Nervosa co-occurent with Intentional restriction of Insulin for the purpose of weight loss / (diabulimia, if it is chosen as a term!)

Apologies all, I have been off for a few days during your discussion.

I think the link should be http://www.wearediabetes.org/learn/diabulimia

Thanks for the link, Paul.