Diabulimia and the Role of School Health Personnel*
Indicates CHES and Nursing continuing education hours are available. Also available at: http://www.ashaweb.org/continuing_education.html
Julie Hasken, Student, (firstname.lastname@example.org), 329 Pershing Building, Truman State University, Kirksville, MO 63501.
BACKGROUND: Diabulimia, the omission or reduction of insulin use by persons with type 1 diabetes, is a harmful method of weight control. The purpose of this article is to present school health personnel with the information they may need to become more aware of the possibility of diabulimia in their students—especially females—with type 1 diabetes.
METHODS: A review of the somewhat limited medical and diabetes-related organizations' literature on diabulimia was conducted to establish the role that school health personnel could play in raising awareness of students with this condition as well as education for diabulimia prevention.
RESULTS: Since insulin encourages fat storage, many with type 1 diabetes have discovered the relationship between reducing the amount of insulin they take and corresponding weight loss. Improper regulation of needed insulin treatments poses serious health problems that may require immediate medical attention.
CONCLUSION: School personnel, especially those in the Coordinated School Health Program areas of comprehensive school health education, school health services, and guidance and counseling services have key roles to play in the prevention and recognition of diabulimia in students with diabetes.
While adjusting to the changes of puberty, the adolescent years are a period of rapid physical and psychological growth and development.1 During this time, to control weight and to overcome body dissatisfaction, some adolescents commonly diet or exercise. Others may resort to more severe options such as binging and purging, the use of laxatives, or adherence to an overly strict exercise regimen. Because weight management during this stage of development can be especially difficult for those with type 1 diabetes, some diabetics may restrict or omit insulin, a condition known as diabulimia, as a form of weight control.2
The purpose of this article is to present school health personnel with the information they may need to become more aware of the possibility of diabulimia in students, especially females, with type 1 diabetes. A review of the somewhat limited medical and diabetes-related organizations' literature on diabulimia was conducted to establish the role that school health personnel could play in the recognition of students with this condition, as well as education for diabulimia prevention.
Type 1 diabetes, affecting nearly 21 million adults and children in the United States,3 is the result of an autoimmune disorder which causes the body to attack its own insulin-producing pancreatic cells. At present, 15,000 children are diagnosed with type 1 diabetes each year.4 To control their condition, type 1 diabetics must have injections of insulin multiple times each day. The body requires insulin to process glucose, a necessary energy-creating nutrient. Without the ability to process glucose, the body will break down other sources, such as fat and protein, to obtain the necessary energy to function.2
Adolescent females with type 1 diabetes are a relatively high risk population for eating disorders, as they are nearly twice as likely to experience an eating disorder than those without the condition.1,5 Additionally, adolescents with type 1 diabetes tend to exhibit increased difficulty in maintaining optimal weight and also are more inclined to be concerned about their weight than their nondiabetic counterparts.6 Before diagnosis and treatment, individuals with type 1 diabetes are likely to lose a large amount of weight. However, once treatment begins, the weight usually returns. By controlling diabetes with insulin injections, many diabetics face a constant struggle with their weight.1 As insulin encourages fat storage, many people with type 1 diabetes have discovered the relationship between reducing the amount of insulin they take and their corresponding weight loss.7
Diabulimia, only recently receiving attention, is not a medically recognized condition; however, the American Diabetes Association has acknowledged the condition for quite some time.1,7 The lack of proper insulin treatment in those with diabetes may lead to many harmful physical effects. Reducing insulin to lose weight increases the risk of dehydration, break down of muscle tissue, and fatigue in the short term; if this behavior continues, it may also result in kidney failure, eye disease leading to blindness, vascular disease, and even death. It is estimated that between 30% and 40% of adolescent and young adult women with diabetes skip insulin after meals to lose weight.1 Improper regulation of needed insulin treatments poses serious health problems that may require immediate medical attention, and, unfortunately, many parents of students with diabetes, as well as their primary care providers, are unfamiliar with the disorder.7
The Role of the School Health Educator
School health educators can integrate education for prevention of diabulimia into Comprehensive School Health Education topic areas along with lessons about the more common eating disorders such as anorexia and bulimia. When presenting information on all eating disorders, it is recommended that the primary focus be on participating in daily physical activity and healthy eating behaviors.8 If the emphasis is placed on achieving a specific, desirable weight, the disordered behavior may be reinforced, and the program would become ineffective.8 The school health educator may also wish to conduct an open-ended discussion about the perception of body weight and feelings about a regimented diet plan.9 These questions should never focus on a specific weight or activity such as binging or exercising, and no food should be labeled as good, bad, or healthy.9 Additionally, the health educator may also have all students complete a food diary which would allow the teacher to observe any unusual patterns in a student's food intake.8
Positive mental health education, including anger management and problem-solving skills, should be included in the school's health education curriculum.10 By including these topics in the health curriculum, not only are all students taught positive interpersonal communication and coping skills, but students with diabetes can also learn how to effectively cope with their diagnosis. Effectively dealing with emotional barriers is critical in the initial stages of coping with the condition. If positive coping skills are not attained, application of diabetes self-management knowledge is unlikely.11 To further interpersonal communication skills, the health educator should try to involve the family of the student with diabetes into the classroom-based activities; possibly using take-home worksheets or holding parent-teacher conferences.8 These types of family-based interventions can be beneficial to students with diabetes because families may not be aware of the signs of diabulimia, thus, they may inadvertently act as enabling factors. Furthermore, since youth are not only influenced by their families but also by the mass media and peers, health educators may wish to integrate media advocacy and the media's affect on food intake and portion distortion lessons into the curriculum. Additionally, a health curriculum can address peer influence on healthy eating habits by providing information on how to reduce peer teasing and improving body dissatisfaction and self-esteem.12
Although the following suggestions are not specific to those with diabulimia, health educators should also be aware of the special needs of those students in their classrooms affected by diabetes. The American Diabetes Association created a list of 11 suggestions to follow in the classroom: “(1) Every child with diabetes is different, (2) Don't draw unnecessary attention to your student's condition, (3) Provide inconspicuous and gentle reminders, (4) Do not put a ‘label’ on the student with diabetes, (5) Do not sympathize: empathize, (6) Always be prepared, (7) Use the buddy system, (8) Allow unrestricted bathroom breaks, (9) Be patient, (10) Keep the lines of communication open, and (11) Knowledge is power.”13
The Role of School Health Services Personnel
School health services personnel are trained to detect the early physiological warning signs of eating disorders (weight loss, excessive thirst, frequent urination, low energy, nausea, and fruity-scented breath). Many times, people with diabulimia are ashamed or embarrassed by the behavior and try to hide the condition.14 Embarrassment often manifests itself as poor body image, low self-esteem, depression or anxiety.14 Behavioral warning signs also include frequent trips to the emergency room for diabetic ketoacidosis; however, diabetics who continue to take basal insulin and only skip the rapid-action insulin may not experience ketoacidosis.15 Disordered eating behaviors among diabulimics are similar to those with bulimia nervosa; they may skip meals or reduce/eliminate sweets followed by intense over eating and a strong sense of guilt.16 Many times diabulimics are uncomfortable eating around others and may hoard food to eat later in secret.16 These students are preoccupied with their weight and body shape and have unusual attitudes toward food and caloric intake.17 Because of the obsession with weight control, many insulin-restricting diabetics are not concerned with the long-term consequences of insulin omission.14 If school personnel notice that these symptoms persist in any students, especially females with type 1 diabetes, it is suggested that they make an inquiry into the student's insulin-taking behaviors and make the appropriate medical referral.1 Obtaining accurate information about the disordered eating from the student may be difficult; therefore, continued communication between patient and the medical professional is necessary to correctly diagnose an eating disorder.18 Current eating disorder health risk assessments may be ineffective for students with diabulimia because most assessments do not contain information about insulin omission.8 Although diagnosing an eating disorder is difficult and often the condition is not found until the behavior has already become habitual, a single screening question such as “I take less insulin than I should” has been utilized to identify students at risk for diabulimia.19 Frequently, those with diabulimia do not wish to disclose information about the eating disorder to the physician. They may, however, discreetly mention warning signs during casual conversation to the physician, nurse or other medical professional in hopes that the medical staff person will recognize warning signs.18 In addition, students frequently do not seek medical attention for diabulimia directly, but rather for the more debilitating effects including esophagitis, abdominal discomfort, or dysphasia.18 If a student does show signs of diabulimia, to prevent them from not correctly regulating their insulin during the school day, school health services personnel can, if possible, assist the students with insulin preparation and supervise its administration.11
School health services personnel may also facilitate the creation of a “Diabetes Medical Management Plan” for each student with diabetes.20 This plan should delineate the specific roles of the teacher, other school personnel, students, and parents. The plan should also address the following: frequency of blood glucose monitoring, doses/times for insulin administration, meals/snacks (including times and amounts), symptoms of low and high blood glucose, and the ability to check for ketones if deemed appropriate by the student's primary care provider.20 By creating the management plan, school officials are better prepared to monitor the eating habits, body weight, and frequency of high or low blood sugars which are symptoms of diabulimia. The American Diabetes Association recommends that middle school students with diabetes be able to administer their own insulin with supervision.20 If school policy requires that a middle school student be supervised while administering his or her own insulin, this may possibly reduce the number of students who are able to omit insulin treatment during the school day. Additionally, if a student is experiencing low blood sugar, the student should be supervised regardless of age.20
Although not the primary responsibility of school health services personnel, once a foundational level of health information about diabetes and diabulimia has been understood by the student, the school nurse should periodically reevaluate the student's knowledge to determine any gaps.11 In collaboration with school health educators, school nurses may also try to determine which type of teaching/learning style would best suit the student with diabetes. The Diabetes Youth Curriculum: A Toolbox for Educators suggests there are 4 distinct learning styles: concrete sequential learners, concrete random learners, abstract sequential learners, and abstract random learners.21 Concrete sequential learners tend to prefer tactical, hands-on learning experiences, in which the person is able to deduce logical information. Concrete random learners may prefer problem-solving trial and error situations with limited direction to independently learn new information. Abstract sequential learners tend to have strong analytical skills and prefer reading, writing, and listening to new information. Abstract random learners tend to be kinesthetic learners who typically are emotional and imaginative. By determining which teaching styles best meets the learning style and needs of the student with diabetes, student learning frustration will likely decrease, and compliance will likely increase.11 If school health services personnel are working with a student who requires supervision of insulin treatment, using the appropriate teaching style may better mediate the self-management process for the student.
The Role of School Guidance and Counseling Services Personnel
Throughout the school day, in addition to the school health services personnel, the school psychologist or school counselor may be made available to the student. Similar to those with other eating disorders, students with diabulimia often deny their harmful behaviors and may even blame other physiological conditions for their uncontrolled blood sugar levels.22 School guidance and counseling services personnel need to understand that anger and denial behaviors may be a manifestation of their fear of inevitable weight gain.23 Often times, the family of an adolescent with diabetes knows little, if anything, about diabulimia, further enabling the harmful behavior. Parent education, support groups, and family counseling are also suggested to aid the entire family in coping. Furthermore, diabulimia hinders a student's academic and social development which is critical during the adolescent years.24 Therefore, diabulimia requires immediate psychosocial intervention.11
For intervention and treatment, it is recommended that a complete psychiatric evaluation be conducted prior to the placement decision. Some students with diabulimia may require in-patient services at a facility specializing in eating disorders, and others may remain in the traditional school setting. Counseling on interpersonal relationships, communication with family and friends, as well as discussions about situations which may induce diabulimic behaviors are extremely important.11
If possible, all school health personnel should work together to accommodate the student with diabulimia and to promote the health of all students by improving their knowledge and behaviors in regard to healthy diet and exercise to prevent disease. For example, all students in the physical education program should have the opportunity to learn how to correctly calculate their body mass index to understand healthy weight as well as to monitor changes in body composition over time. In addition, school health personnel could provide in-services to the other teachers and staff on the guidelines suggested by the American Diabetic Association for working with students with diabetes, as well as the definition, prevention, and recognition of diabulimia in students with diabetes.
In an effort to control their weight by not correctly regulating their insulin levels, students with type 1 diabetes place their health at risk. It is important that school health personnel increase a school's staff and student awareness of diabulimia, recognize the warning signs of insulin abuse, and be supportive of those students with the condition.