 The next item of business is a members business debate on motion eight, not not Fe in the name of Annie Wells on raising awareness of dire bulimia. The debate will be concluded without any questions being put and with those members who wish to take part in the debate. Please press the request to speak butons now in a column Annie Wells to open the debate. Ms Wells, seven minutes are thereabouts please. Thank you. People who are speaking on this debate today. The reason for today's debate is today's much-needed public awareness of diaembolemia, an eating disorder, although estimated to affect 40 per cent of young women aged between 15 and 30, and 11 per cent of teenage boys with type 1 diabetes is still relatively unknown. The condition who involves a person with type 1 diabetes, omitting insulin to lose weight, has only recently gathered media attention, As such, we are only just beginning to see the term diablolemia used in everyday language. Not officially recognised medically, diablolemia on strike at various areas in real threat to its victims and as such has now been coined as a world's most dangerous eating disorder. As an eating disorder combined with a chronic illness the complexities of explaining diablolemia often extend beyond that of more commonly known eating disorders, anorexia nervosa, and bulimia. The reason why today I will give full and due attention to explaining exactly what Diablemia is. In understanding what the condition is and sharing this knowledge with people around us, we can go some way in spreading awareness of the condition. So what is Diablemia? Diablemia is a condition that can affect people with type 1 diabetes, a lifetime autoimmune condition thought to affect around 30,000 people in Scotland. When you have type 1 diabetes, cells in your pancreas are attacking, attacked, making it unable to produce insulin, a vital hormone that takes the glucose from our food into your bloodstream and delivers it to all the different cells of our bodies. Without insulin, our body cannot get the nutrients it needs, which is why people are first diagnosed with diabetes. They usually have lost a lot of weight and often feel irritable and low. Upon diagnosis, sufferers will begin to inject those of insulin, calculated to match what they eat, and, significantly, it is after taking insulin that sufferers will often regain the weight that they lost when they were ill, and this will usually stabilise at a weight that is slightly heavier than the healthy and non-diabetic population. Importantly, in understanding Diablemia, it is his own to this weight gain that people who need insulin are often faced with a terrible choice. They can lose weight without even having to diet by restricting their insulin or by stopping taking it altogether. The signs therefore may not be obvious. With Diablemia, there is no need for food restriction, purging, exercise or any of the classic symptoms often related to eating disorders, so the condition can go unnoticed. Sufferers will also show no signs of weight loss. They can retain normal eating habits and appear absolutely fine to their friends and family around them. On a recent BBC documentary on Diablemia, a young woman with a condition sat down with her parents and told them that there had been periods where she had not taken insulin for up to two weeks at a time, something that they were oblivious to, understandably, despite living in the same house. The effects of that are huge. Without insulin, your body is unable to take the nutrition from food, patients can suffer from permanent loss of eyesight, pains and loss of sensation in their feet and hands, kidney damage and eventually become blind, need dialysis or transplants or suffer from amputations. The damage is cumulative rather than reversible. Unlike ordinary starvation, which is mostly reversible over time, given enough nutrition, this is why Diablemia has come to be known as the world's most dangerous eating disorder. Statistics have shown that, although the 10-year mortality rate for people with diabetes is 2 per 1,000 people and for anorexia it is 7 per 1,000 people, Diablemia has faced a much higher mortality rate of 35 per 1,000 people affected. Speaking in the same documentary, Becky Rudkin, a woman from Aberdeen, spoke of her 10-year battle with Diablemia, a condition that resulted in her suffering three diabetic comas and something she was eventually only saved from after being sectioned. Raising awareness of Diablemia is key to prevention. Work is being done. We are hearing about the condition more and more in the media and examples of good practice are taking place up and down the country. In Glasgow last year, Diabetes UK heard a professional conference featuring a discussion on Diablemia, and for many of the 3,000 people in attendance, that will have been the first time they have ever heard of the condition. In the north of Scotland, where the specialist eating unit exists in Aberdeen, diabetic clinicians and eating disorder clinicians are holding workshops together and establishing good permanent working links to support patients together. That is something that we should work to build on. As ever, there is always more to be done. Good practice exists, and among health professionals, clinicians are fairly familiar with the symptoms of the condition. Diagnosis does occur through the use of a specialist questionnaire and blood testing, but once diagnosed, there is no official diagnosis code for Diablemia. Within the NHS framework, insufferers can be classified as having an eating disorder, not otherwise specified, or an atypical eating disorder. As a result, there is no current NHS guidelines on how to deal with the issue, and patients are not always treated with the interdisciplinary approach that is needed—an issue that was raised specifically by a family that I have been in contact with who have been personally affected. The treatment needed for a diabetic with an eating disorder is quite different from that of a person without diabetes. I would therefore like to use that opportunity to urge for integrated thinking across the country when it comes to covering the two elements of care. To finish today, I once again would like to thank members who have spoken in this debate and showed their support for raising awareness of Diablemia. I have been very proud to bring the subject forward to the chamber, and I hope that that will have generated more interest in a subject that deserves greater degree of publicity. We are required to tackle this issue head on, and that is why I am pleased that sufferers of the condition are feeling more comfortable in coming forward to share their often very harrowing stories. While diabetes is a condition that most, if not everyone, is acutely aware of, Diablemia is a condition that may well exist within people's families, but relatives are completely unaware of the suffering that their loved ones are going through. By having that condition officially medically recognised, I believe that that would be a major step forward in helping to raise awareness of the disorder, as well as helping to gain better support for those who are living with Diablemia. That has been an important debate, and I hope that that is a subject that we can raise again in the chamber. I move the motion in my name. Thank you. No need to move a motion, but that does not matter. I am calling Emma Harper, and I would like to call Mr Whittle, but he is not pre— There you go. Ms Harper, please. Thank you, Presiding Officer. I would like to congratulate Annie Wells for securing this important debate. As someone who has type 1 diabetes and a registered nurse, I am grateful to have the opportunity to speak in this debate today. It is important to emphasise that this debate is about raising awareness of a condition that has not been officially recognised. As co-convener of the cross-party group for diabetes with Dave Stewart, I appreciate that raising awareness of this eating disorder is crucial. It is estimated that, across Scotland, there are almost 35,000 persons living with type 1, and Diablemia is sometimes referred to as EDDMT1—Eating Disorder Diabetes Malitis Type 1. It is difficult to diagnose, and Diablemia is an extremely complex condition where, over a period of time, a person with type 1 either stops or restricts the amount of insulin that they inject in an attempt to control their weight. Why do people do it? There are listings on the Diabetes UK website that talks about obsession with food labels, negative attention to weight, hypo-binging, constant awareness of numbers, parent attitude towards type 1, shame over management, negative relationships with healthcare providers and difficulty losing weight due to insulin. Insulin, as Annie Wells mentioned, is the protein that acts as a bridge to allow energy supplying glucose into the blood to transfer into cells to support metabolism. When someone omits their insulin, it causes the blood sugar levels to really get high and results in metabolism of fat and protein in the muscle, as the body needs an energy source. That is what leads to the weight loss. As the physical health needs of those suffering from Diablemia also require mental health support, it can cause a range of emotions, feelings of depression, shame, guilt, low self-esteem and having to closely monitor the diet and everyday stress of life. I spoke with one of the nurse specialists this morning from NHS Dumfries and Galloway from the diabetes team. I wanted to find out about what NHS Dumfries and Galloway have for people who are suspected of having this eating disorder. I was informed that NHS Dumfries and Galloway now have a new dietitian who specialises in weight management and eating disorders, and his remit will include referrals, assessing and supporting type 1s with Diablemia. That is good news for folks in the south-west of Scotland. For health professionals, we ask for them to look out for type 1s who focus on weight control rather than blood glucose control, because that is one of the first signs that a focus on weight is the most important thing rather than blood glucose control. The research suggests that women in particular are at a higher risk for developing Diablemia. I was surprised to find out that an estimated 60 per cent of women with type 1 diabetes will have experienced a clinically diagnosable eating disorder by the age of 25. That is a profound statistic. The same research also suggests that men with type 1 have a much higher drive to lose weight than their non-diabetic counterparts. When I was researching ahead of this debate today, I found that the documentary, Diablemia and Me, was quite interesting for anybody to google and look at to help raise awareness of this condition. The one lady in the documentary, her name is Becky Rudkin, said that she does not get a day off from diabetes. There are a lot of numbers dictating your life, from calorie counting to watching the scales. I can identify with focusing on those numbers. There are carb numbers, there are blood glucose numbers, there are insulin unit numbers, and do not get me started on ketones. Becky is correct that there are a lot of numbers dictating how one should manage one's own autoimmune disease to prevent complications and stay well. My message as I am closing is, congratulations to Annie Wells for a comprehensive overview of the causes of and the condition and the effects of Diablemia. Great job, thank you. Thank you very much. Brian Whittle is followed by Colin Smyth. Thank you, Deputy Presiding Officer. I am delighted to be able to speak in this debate, and I congratulate my colleague Annie Wells for securing the time in the chamber to highlight and discuss the issue. I would also like to thank Diabetes Scotland for the briefing papers. Although I am a member of the CPEG group on diabetes and continually being educated by Emma Harper, I have to say at the outset that the condition was not familiar to me until fairly recently. I am, of course, aware of other eating disorders such as bulimia and anonexia, which I have some experience of and you may be surprised to hear from the world of sport, nearly always in women. In their drive for excellence in track and field, I know of distance runners who have taken their dietary habits too far and crossed into the realm of eating disorders. I have also had to help a person close to me whom bulimia became a problem, against someone who was immersed in sport, whom you would not necessarily imagine would fall into that unhealthy cycle. I mention that only because those conditions can very easily be hidden. Diabilemia is a condition that seems to have potentially even more dangerous outcomes because it is associated with the condition that, not properly treated, can in itself lead to life-threatening situations. Those suffering from type 1 diabetes have a constant need to control their blood sugar level by injecting insulin. If more or less properly, those with type 1 diabetes can live a very normal life in just about every way, I have mentioned before in this chamber that I am lucky to coach an athlete with type 1 diabetes and he has gone on to medal at Scottish level in the 1500m. However, the idea of controlling weight loss by reducing their insulin intake is quite shocking, especially when it is suggested that although that condition can affect men, 60 per cent of females, as has been mentioned by Emma Harper with type 1 diabetes, will have experienced a clinically diagnosed eating disorder by the age of 25, 60 per cent. Unlike most eating disorders, the foundation for that condition lies, I think, in a psychological issue, an issue of how one sees oneself and how one would want to look. That is certainly an issue of self-deprecation and a lack of confidence that opens up a whole can of worms around public perception of what Luke is desirable and what is not predominantly driven by the media, but perhaps that is a debate for another day. In securing today's debate, this Parliament is able to raise the issue, to shine a light on it, so to speak, that will hopefully go some way to bring it to the attention of the greater public. Perhaps more importantly, it may reach out to those who are suffering from that condition and let them know that there is help out there for them and they do not need to suffer alone. The diabetes improvement plan indicated that the deployment of psychologists has made a significant inroad into the issue in the areas of deployment. The further support and training that is made available to staff to increase the level of psychological assessment skills has to be highlighted and the roll-out continued. Healthcare professionals, family and friends need to be aware of the tell-tale signs that could endigate that diabolemia. I will not go into them again, as they have already been mentioned. I recognise that Diabetes Scotland is calling for the action to improve recognition and management of the condition and hopefully this debate is part of that raising of awareness. Once again, I congratulate Annie Wells for bringing this debate to the chamber and for anyone with questions or needing advice to contact Diabetes Scotland on their helpline because this is the condition that no one should have to live with. Colin Smyth, we have followed by Clare Haughey. Clare Haughey, we have a last speaker in the open debate. Mr Smyth, I would like to echo the thanks of others to Annie Wells for her motion that has allowed this debate today and given us MSPs the opportunity to play a small part in raising awareness of diabolemia, a condition that, as we have already heard, is incredibly dangerous but also poorly understood. Although I am my party's spokesperson on public health and a member of the Parliament's Health and Sport Committee, I have to confess that, until recently, my own understanding, like many others, was limited. I want to commend Diabetes UK and other charities for the work that they are doing to try to tackle the lack of awareness of the condition. I also want to place on record thanks to the BBC for the recent BBC3 documentary, Diabolemia, the world's most dangerous eating disorder, which was mentioned by Annie Wells and Emma Harper. That documentary brought home to me and others that the real-life human impact of diabolemia for three young sufferers and their families. To other members, if you have not watched the documentary, please do so on BBC iPlayer. The lack of awareness surrounding diabolemia makes identification and treatment more difficult and contributes to the stigma associated with the condition. Until we improve recognition and understanding, it will be hard to improve early intervention and provide better treatment. Those with diabolemia are faced with the dual burden of both type 1 diabetes and an eating disorder. There are serious physical and psychological symptoms associated with both, and the interrelation of the two makes it a particularly high-risk condition. The potential physical complications of diabetes such as diabetic ketoacidosis, damage to eyesight, kidneys and nerve endings are significantly heightened by taking less insulin than required, and the possibility of doing less than damage is high. Likewise, the hyper-awareness of food and diet that is necessitated by diabetes can entrench and perpetuate the unhealthy relationship with food that underpins eating disorders. In addition to the severe risk associated with diabolemia, its prevalence is also a cause for serious concern. As the motion notes, research has found that up to 40 per cent of women aged 15 to 30 with type 1 diabetes have the condition. Although it is thought to be less common amongst men, men with type 1 diabetes have been found to exhibit a higher drive for thinness than their non-diabetic counterparts, putting them at risk of diabolemia. Indeed, a recent study in Germany found that 11.2 per cent of boys between 11 and 19 will emit insulin to lose weight. However, as it is not a recognised medical condition, it is all but impossible to gather accurate information about its prevalence and the risks that it poses. There are no reliable statistics for exactly how many people suffer from diabolemia, and thus cause the result of it being recorded as a result of diabetes complications. That is not only mass the scope of the problem, but limits analysis of its impact and relevant trends. If we are to improve awareness, prevention and treatment of diabolemia, we need a better understanding of the issue. Recognising it as a specific medical condition is crucial to building a comprehensive view of who diabolemia affects and how. The complex nature of the condition can make it difficult to secure the right treatment. Too often, diabetes experts may lack an adequate understanding of eating disorders, and mental health professionals may not be familiar with the challenges of diabetes. It is a unique condition that requires specialist treatment and a multi-faceted approach. Nice guidelines on diabetes highlight the heightened risk of eating disorders that those with diabetes face. Likewise, the guidance on eating disorders now has a subsection on diabetes for all categories of eating disorders. Crucially, that includes a specific treatment plan for those who have taken the appropriate dose of insulin. It is encouraging to see the clinical guidance beginning to reflect the reality of the condition, and I welcome the progress that is being made on that matter. However, many patients are still struggling to get suitable treatment. There is still a great deal more to do. The sign guidelines are yet to be brought in line with Nice on that matter, and there is still insufficient knowledge among healthcare professionals on how to identify and support people with diabolemia, so that needs to improve. To deliver informed evidence-led treatment for diabolemia across Scotland, we must do more to facilitate the collaboration between the two fields and develop expertise on the condition. By making that happen and raising awareness of the condition, we can play our part in ensuring that those with diabolemia get the treatment and support that they need. I refer members to my register of interests, in particular to the fact that I am a registered mental health nurse, holding a current registration with the NMC into my honorary contract with Crater Glasgow and Clyde NHS. I, too, would like to add my thanks to Annie Wells for bringing this important issue to the chamber for debate today. Most people will not have heard of diabolemia. It is not an illness classified in either DSM-5 or ICD-10, both of which are the internationally recognised classifications of disease and health-related problems. It is not surprising that most healthcare professionals may not have heard of it either. In preparing for today's debate, I even found it difficult to find published research on diabolemia. I do note, however, that insulin omission should now be considered a clinical feature when diagnosing anorexia and bulimia. I sincerely hope that MSPs are able to use our debate today to increase its recognition, not only amongst the healthcare and research communities, but also with the public. As we have already heard from other speakers, the word diabolemia merges the words diabetes and bulimia. Type 1 diabetes is treated by regular injections of insulin to control blood glucose levels, and diabolemia is the term that describes where someone regularly, deliberately reduces the amount of insulin that they take to control their weight and alter their body shape. Diabolemia itself is certainly not a household name, but it is a condition that could possibly affect a large proportion of our population. As we have already heard, there are around 30,000 people diagnosed with type 1 diabetes in Scotland, and from the little research that is into diabolemia, a significant percentage could be susceptible to being affected by it. Although Diabetes Scotland warned to treat those figures with caution, one study has found that estimates of insulin omission have been reported in up to 40 per cent of people with diabetes. Other research from Germany suggests that over 10 per cent of males between 11 and 19 omitted insulin to lose weight. I am sure that we all agree that those figures are rather alarming and could just be the tip of the iceberg in terms of the numbers of people affected. What happens when someone with type 1 diabetes omits their insulin? Blood glucose levels increase, hyperglycemia leads to polyuria, essentially passing an increased amount of urine, and that means that any calories are excreted and, as a result, are not used and that the body is starved of energy. If hyperglycemia is untreated, it becomes life-threatening diabetic ketoacidosis, and if it is left untreated, it is fatal. The longer-term effects of diabolemia are equally dangerous. Not taking enough insulin over a longer period of time can shorten life expectancy. Other complications linked to diabetes such as retinopathy, neuropathy and nephropathy can occur earlier in life, and it can also lead to infertility. In cases where diabolemia leads to severe diabetic ketoacidosis and is not treated, heart and organ failure occurs. To anyone who is struggling with his illness, I would make an impassioned plea, reach out, talk to someone you trust that is help available and, with that help, you can get better. Before I end, I would like to pay tribute to my SNP colleague, Dennis Robertson, who served the Aberdeenshire Waste constituency with distinction between 2011 and 2016. Councillor Robertson is a true champion of raising the awareness of eating disorders. During his time in this Parliament, he has spoken many occasions of his own family's experience of eating disorders, leading to the tragic death of his daughter. Despite Dennis no longer sitting in this Parliament, I am pleased to say that there are still members who will carry the torch to raise awareness of such devastating conditions. I again thank Annie Wells for securing today's debate on diabolemia. I hope that we, as a Parliament, have been able to raise the awareness of this condition so many more people can come forward to get the help that they need and to recover. I also join others in thanking Annie Wells for bringing what is an important debate to Parliament today. I am pleased to be able to respond on behalf of the Scottish Government. We want to continue to drive improvements in mental health services, and we are absolutely committed to ensuring that everyone, including people with diabetes, who need access to high-quality mental health services have access to that care when and where they need it. In that respect, it is right that we recognise the efforts of all the people and organisations across Scotland involved in raising awareness and treating eating disorders. We also want the best for people living with diabetes. Raising public awareness of using insulin to control weight is important. I assure members that the behaviours and risks that are involved are well known to clinicians, particularly those who are working in diabetes and mental health services. I accept, however, that there is always scope for greater awareness and understanding among professionals and for the development of improved specialist support in response to that behaviour. We are working with NHS Scotland and partners to do just that and to ensure that services are in place to meet the needs of people who are at risk and who use insulin to control weight. Type 1 diabetes is more than simply a physical condition. Like anyone suffering a serious chronic condition, there is often a psychological impact. Anyone who needs support should, of course, get it. However, growing up with diabetes is challenging enough without the pressures and expectations of modern life, and that is why we need to support young people with diabetes in particular and think about their health and social wellbeing. Young people need good support to manage their condition through their life from childhood to adulthood. Diabilemia, as has already been said by many, is not a diagnostic term. It is, however, important that the behaviour of using insulin to control weight is recognised. Misusing insulin to reduce weight is clearly unhealthy and dangerous, and it is important that people are equipped to better manage their own health. The dangers of underusing insulin to lose weight in the long term can be severe. As others have mentioned, chronic poor diabetic control can lead to the loss of limbs, kidney damage, blindness, heart damage and other serious complications. I also recognise that determining the prevalence is difficult. It is hard to quantify the problem because people tend to hide it from family, friends, carers and clinicians. No matter how the behaviour of using insulin to control weight is officially recognised, what is important is that people demonstrating such concerning behaviour receive the care, help and support that they need when and where they need it. Our new mental health strategy aims to do that. The guiding ambition of the strategy is simple. We must prevent and treat mental health problems with the same commitment, passion and drive as we do for physical health problems. It also has a focus on improving the quality of care and ensuring equal access to the most effective and safest care and treatment. That is important for people living with diabetes and those with eating disorders, as for anyone else. Through the delivery of the strategy, we seek to improve access to psychological therapies and to treatments for children and young people. We are supporting the development of a digital tool to support young people with eating disorders. We also want to highlight the important role of liaison psychiatry in providing a specialist mental health service across a wide range of acute services and physical illnesses. We look to NHS Scotland and partners to improve liaison psychiatry services and mental health provision for acute patients. In line with best practice, NHS services should have local mental health support for people with type 1 diabetes. The sign guidelines for the management of diabetes recognise how common mental disorders are and it gives information on mental health assessment and treatment. The third sector, primary care and specialist services all have an important role to play in providing support and advice to people who misuse insulin in order to lose weight. There are good practice examples to highlight in respect of specialist services. For example, the NHS Lothian Diabetes Mental Health Service currently has a dedicated liaison psychiatrist and psychiatric nurse resource specifically for diabetes. I know that this service is highly valued by clinicians and patients and has demonstrated good clinical and financial outcomes. The service does see patients with an eating disorder and who use insulin to control weight. Those patients are seen as a priority by the eating disorder service at the Royal Edinburgh Cullin Centre when referred on. Individuals who are referred to eating disorder services can expect to receive the highest quality of care and support from the NHS. A wide range of community hospital and specialist and patient services are in place across Scotland to meet the needs of people living with an eating disorder. In 2009, I had the pleasure of formally opening the Eden unit in Aberdeen, a specialist NHS eating disorder and patient unit serving the north of Scotland. It continues to provide valuable care and specialist support. Emma Harper also mentioned the work in NHS Dunfries and Galloway with the new dietician appointment, which will help to improve services for weight management and eating disorders in the south of Scotland, which is very important. Brian Whittle mentioned the Diabetes Scotland helpline, and the involvement of Diabetes Scotland in the area is hugely important. I also thought that he made an important point about the wider societal pressures that drives people of any age, but particularly young women, to want to look a certain way. That is an issue that is really hard to tackle. Colin Smyth referred to the BBC documentary, The Most Dangerous Eating Disorder. It is absolutely well worth a watch, very powerful indeed. Clare Haughey outlined very well the consequences of emitting insulin and, quite rightly, pay tribute to former MSP councillor, Dennis Robertson, who is still champions the cause of eating disorders. Let me close by saying that we are very ambitious for continued improvement. I want to repeat my thanks to Annie Wells for raising an issue that I think many people knew little about, and that is one of the really powerful things about members' business, the opportunity to raise that, and hopefully some of the media attention around this important issue will raise awareness. Importantly, I hope that I encourage people who may have concerns and may have a problem in this area to seek help, because help is there and we want people to get the support that they need. I hope that I have been able to give the Scottish Government support today for the work that is going on in this area, and I thank everybody for their contributions to this important debate. Thank you very much. I say to Annie Wells in 18 years, and here I have never heard of this before, so it is very important that you raise this on members' debate. That concludes the debate, and I suspend the meeting until 2.30.