Critically evaluate the (potential) role of self-esteem in the onset of Diabulimia

Question 1

ORDER of things

Answer 1

1) Facts about prev of ED and diabetes
2) What is diabulimia?
3) Biological explanations
4) Link of diabulimia & SE (A &B)
5) Depression & SE
6) Self concept
6) Treatment implications

Question 2

1) Facts about prev of ED and diabetes (3)

Answer 2

A. 60% of women with type 1 will have experienced an ED by the age of 25 (Colton et al. 2015)

B. Research indicates that the onset of diabetes occurs prior to the eating disorder in 90% of cases (Marcus & Wing, 1990).

C. Estimates of insulin omission have been reported in up to 40% of people with diabetes (Pinhas-Hamiel & Levy-Shraga (2013)

Question 3

2) What is diabulimia?

5

Answer 3

• Individuals with type 1 diabetes who engage in insulin omission in order to promote weight loss = diabulimia

BUT this term excluded other eating problems in individuals with diabetes and implies that eating problems in those with diabetes are essentially distinct from those in individuals without diabetes
**EDDMT1 = another diagnoses for all people with type 1 diabetes and an ED.

• NOT a clinical diagnosis BUT patients do identify with the term (may be how they present to the GP) (Inclusion of the term is encouraged)
• NOT yet in DSM 5 officially (but as “people with type 1 diabetes may omit or reduce insulin to minimize carb metabolism”) is recognised in most recent NICE
• Severe consequences – organ failure and death

** thus, diabulimia as used here only looks @ diabulimia as omission of insulin

Question 4

Biological explanations

Answer 4

• Twin studies of binge eating, self-induced vomiting, and dietary restraint suggest that these behaviours are roughly 40 % heritable (Brewerton, 2014)
• Diabetes only partly heritable too (Fraizer, 2014)

so if diabetes and ED’s are only partly genetic, genes can only be explaining part of the picture

Question 5

Link of diabulimia & SE (A)

Answer 5

Olmsted et al. (2008) :
new onset of Diabulimia was predicted by:

a) LOW SE RELATED TO THEIR PHYSICAL APPEARANCE (i.e. when SE was low perception of PA was too)

• The reason most frequently cited by young women with T1D for deliberate insulin omission is weight control (rather than denial of having diabetes/fear of needles) (Rydall et al. 1997)
• may be due to the higher BMI found in diabetes –> higher BMI is an established risk factor for body dissatisfaction, dieting, and associated eating disturbances in young women in Western cultures (Rodin et al. 2002)
• significant differences between participants with and without diabetes in relation to body image dissatisfaction/ concern about weight (Philippi et al. 2013 & Colston et al. 2009):
  diabetes = lower self- esteem related to worse body dissatisfaction

BUT
Falcao + Francisco (2017) didn’t find one tho

BUT

• Only used males & they suggest that males are more satisfied with their body image than females SO the inc of males decreases the % cos males are more happy with body
• Research bias

BUT

• Some have found that males with T1D have a higher drive for thinness (Svensson et al. 2003)
• One study found only a 2% difference in the amount of girls and boys who omit insulin to lose weight (Hevelke et al. 2016)

WHY DID falcao + Francisco (2017) find no difference in non diabetes & diabetes in BID?

• the measures they used were not sensitive enough to pick up maladaptive thoughts in males with T1D (Reas et al. 2012) – NEED BETTER SCALES
• • may not just be predominantly females with this condition = limited data & data that is conducted is tainted

Question 6

Link of diabulimia & SE (B)

Answer 6

• Global SE is affected (their self efficacy & sense of control)

CONTROL EVIDENT IN ED?

• yes; individuals with ED, the sense of control is often obtained by continuous monitoring of eating and body weight and shape (Fairburn & Harrison, 2003)
• dietary restrictions enhance the subjective perception of being in control (Slade, 1982)

BUT
- Majority of research into EDs and control looks at control in the sense of a lack of control over body weight AND eating habits and behaviour –> ED. BUT it’s actually a lack of control in life in general, but they use their body weight restriction to control/constrict their life to make it more manageable (Sassaroli et al. 2008)

DO PPL WITH T1D SUFFER A LACK OF CONTROL FEELINGS?

• yes
• request made to them (i.e. what they can and can’t eat
• lowered sense of control generally & lower sense of control over body –> associated with disordered eating in T1D (Schwartz, 2002 + Hardy 2010)

**onset of puberty will also affect this as puberty can affect feelings of control; important bc the peak age of diabetes is 14

PERCEIVED CONTROL IS IMPORTANT:
a) Those who think diabetes is beyond their control = less motivated for self-care activities including poor insulin control (Mc Sharry et al. 2011) & those who felt in control = made more healthy lifestyle choices (Celano et al. 2013)

DIABULIMIA AND LACK OF CONTROL
- Qualitative study = they all desired power/control over the natural world (their bodies). They discovered a force that they did not quite understand that allowed them to cheat nature and fulfil their desires and gain control of their world (insulin omission). (Balfe et al. 2013)

Question 7

depression + SE

Answer 7

• The risk of significant depressive symptoms is approximately doubled in individuals with T1D (Powers, 2017), = vulnerability for developing disturbed eating behaviour?
• Self- esteem predicts depression & depression predicts low self-esteem (bidirectional)

a) Vila et al. (1995) found that almost half of 52 teenaged girls with type 1 diabetes and an eating disorder also reported significant depressive symptoms and that these girls had significantly higher HbA1c levels (glucose levels) (i.e. they weren’t injecting insulin)
b) Depression predicted disturbed eating behaviour (Olmsted et al 2008)– NOT NEC DIABULIMIA THO

• Eating pathology and depression are concurrent risk factors for each other, suggesting that future research would benefit from identifying factors that are etiological to the development of both constructs.
• need more research on depression & diabulimia

Question 8

Link of diabulimia & self concept

Answer 8

Illness self-concept =often ignored in studies/ not controlled for

WHAT: llness self‐concept (ISC), or the extent to which individuals are consumed by their illness & how much it defines them as a person (Morea et al. 2008)

Illness self-concept is a mediator:

a) When chronic illness plays a central role it intrudes on various life domains and is associated with hopelessness, decreased self esteem (+ self efficacy), and poor adjustment (Abraído-Lanza and Revenson, 2006).
b) Whereas when it plays a less central role = constructive challenge; illness acceptance (Caiser et al. 2008)

Luyckx et al. (2016) – 5 year prospective study –> How does self esteem influence problem areas seen in diabetes? Including depression & food problems?

a) Low self-esteem = more illness self-concept later on = worse adaption over time

** Emerging adults with higher levels of self-esteem were better equipped to cope with the daily challenges of having diabetes, as evidenced by lower scores on several problem areas (food & depression) in diabetes 5 years later

EVIDENCE
a) Rassart et al., 2013 – Lowered self-esteem = indulge themselves into the sick role of “diabetic,” further constricting their self and reducing the attainment of adequate coping strategies. High scores on self-esteem managed to give diabetes a proper place in their lives.
b) fibromyalgia patients found evidence for a strong negative association between illness self-concept centrality and self-esteem (Morea et al., 2008).
.

Question 9

Treatment implications

Answer 9

Current treatments (CBT) aren’t effective:

a) High drop out
b) Bad outcomes

Why?
• In spite of the frequency of diabetes and eating disorders occurring together, individuals impacted by both generally receive separate treatment for each condition, which may be counterproductive. For example, insulin dosage is determined based on an individual’s meal plan. When someone has anorexia and eats little, however, blood sugars and insulin needs are reduced and must be actively addressed.

• Thus explaining why motivations are low

One way to proceed might be to directly address patients’ lowered self-worth and their self-concepts. Experiencing increased self-worth and learning to deal pro-actively with diabetes might render them less vulnerable to being engulfed and subsequent illness-related problems.

** some models/recs kind of hint at this but none address directly i.e. “ teams shoukd be fused to look @ diabetes skills & negavie emotions brought on by what insulin and diabetes means to them”

Question 10

Conclusion

Answer 10

• extremely limited amounts of research concerning Diabulimia
• So important that we begin to understand it, as it is so deadly & life threatening
• The role of self esteem seems to potentially play a very important role in the onset of diabulimia
• it impacts an individuals physical appearance, sense of control & potentially on depression.
• May be mediated by their illness self concept
• Target for therapy & treatment implications