Friday, 14 June 2013

ED

Stone cherubs
Monastery in Melk, October 2012
There's not much I can write about on this blog, due to my self-imposed rules of not breaching patient confidentiality and trying not to write anything that isn't positive and constructive. That's why I am so delighted when something happens at work that I can write about.

In the diabetes department we have quite a few lunchtime educational talks, often from reps trying to sell something. Doctors, Diabetes Specialist Nurses, Therapy Assistants and Dietitians all attend on an irregular basis - there is no compulsion, but the lunches are often attractive. This week, a talk was advertised entitled 'ED and lifestyle'.

Eating Disorders afflict people with diabetes in the same way as in the general population, but Type 1 Diabetes brings with it the 'opportunity' for weight loss by under-dosing insulin or omitting injections. Glucose from dietary carbohydrate enters the bloodstream after digestion, but without insulin it cannot leave the bloodstream to be used for energy or stored as fat. The level of blood glucose increases, and when the renal threshold is exceeded, it is excreted by the kidneys into the urine. Incidentally, this is how diabetes used to be diagnosed before insulin treatment was available - the urine tastes sweet because of the glucose in it. So by ensuring that there is little or no insulin about, calories in food are disposed of before they can cause any weight gain.

The drawback of this strategy is ketoacidosis. If glucose is unavailable as a source of energy because of a lack of insulin, then fat is burned instead, resulting in the production of ketones, which are toxic. If ketones accumulate in the blood then the blood becomes acidic, and this is called Diabetic Ketoacidosis (DKA), which is a very nasty condition, and can be life-threatening. It is what diabetics used to die of before insulin therapy was invented. In addition, maintaining the kind of high blood sugars that are necessary to achieve this metabolic state greatly increases the likelihood of complications such as blindness, kidney failure and nerve damage.

The practice of under-dosing insulin and continuously hovering on the brink of ketoacidosis has been termed 'diabulimia', and it has been proposed in some quarters that it should be formally recognised as an eating disorder associated with diabetes. So when RSB and I found out that there was to be a talk on ED and lifestyle, we thought it would be really interesting, and very relevant to our work. Unfortunately, another meeting about student placements that we really had to attend had been scheduled at the same time.

Nobly, RSB volunteered to go to the student placement meeting while I attended the ED talk. The room filled up, and the speaker started with some slides about how inactive the UK population had become, and how this is contributing to the obesity epidemic. Nothing new for me here, but I wondered what the relevance was to Eating Disorders. I also wondered why so many doctors had turned up, because they are busy people and I didn't think that the topic would be a priority for them.

Two minutes later I quietly slipped out of the room, and went on to the student meeting, which had pretty much finished. RSB filled me in on what had happened there, and asked what I had learned in the ED lecture.

"You thought the same as I did, didn't you, that ED stood for Eating Disorders" I said.

"Yes," he replied, "Doesn't it?"

"Ah," I said. "No. It turns out that ED doesn't stand for Eating Disorders where diabetes is concerned."

"Oh." He thought for a moment. "What does it stand for, then?"

"Erectile Dysfunction."

Once he had finished laughing, he amused me further by telling me that he had met the speaker just before the talk, and apologised that he wouldn't be able to stay, but said that we were very interested in ED and lifestyle and I would be there and would feed back to him, and we could take the speaker's contact details if we needed to follow up later. On reflection, I don't think we will.

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