Eating disorder and type 1 diabetes: overview and summing-up

Clinical characteristics and outcome of 467 patients with a clinically recognized eating disorder identified among 52,215 patients with type 1 diabetes: a multicenter german/austrian study

OBJECTIVE

To compare clinical characteristics and outcome of type 1 diabetes mellitus (T1DM) between patients with and without a clinically recognized eating disorder (ED).

RESEARCH DESIGN AND METHODS

A total of 52,215 T1DM patients aged 8 to <30 years from the prospective diabetes data acquisition system DPV were analyzed. A total of 467 patients had an additional diagnosis of ED according to DSM-IV criteria (anorexia nervosa [AN], n = 141 [female: 94.3%]; bulimia nervosa [BN], n = 62 [90.3%]; and EDs not otherwise specified, including binge-eating disorder [EDNOS], n = 264 [74.2%]). Groups were compared using multivariable regression. Cox proportional hazard ratios were calculated for the association between ED and retinopathy.

RESULTS

After adjustment for age, sex, and duration of diabetes, patients with ED revealed higher HbA1c (no ED vs. AN, BN, or EDNOS, respectively: 8.29 ± 0.01% [67.1 ± 0.1 mmol/mol] vs. 8.61 ± 0.15% [70.6 ± 1.6 mmol/mol], 9.11 ± 0.23% [76.1 ± 2.5 mmol/mol], or 9.00 ± 0.11% [74.9 ± 1.2 mmol/mol]) and a higher rate of pathological insulin injection sites (48.4 vs. 64.3, 64.1, or 62.1%). Furthermore, ketoacidosis (5.7 ± 0.1 vs. 12.1 ± 2.1, 18.0 ± 4.1, or 12.9 ± 1.6 events per 100 person-years) and hospitalization (54.9 ± 0.3 vs. 89.3 ± 6.0, 132.0 ± 12.7, or 91.0 ± 4.4 per 100 person-years) were more common, and duration of hospital stay was longer (4.81 ± 0.01 vs. 11.31 ± 0.21, 18.05 ± 0.48, or 8.44 ± 0.13 days per year). All P values were <0.05. Patients with BN and EDNOS had a 2.5-fold (95% CI 1.3-4.8) and a 1.4-fold (0.8-2.3) higher risk for retinopathy, whereas AN patients had no increased risk (0.9 [95% CI 0.4-2.3]).

CONCLUSIONS

Diabetes health care professionals should be aware of comorbid EDs in pediatric/young-adult T1DM patients. An ED diagnosis is associated with worse metabolic control and higher rates of diabetes complications.

Control and disordered eating in type 1 diabetes

Control is a major topic associated with the management of diabetes due to the importance placed on maintaining healthy blood glucose levels in this condition. Such an outcome can be influenced by individuals' sense of mastery over the disease, and more generally over their environment. In response to a diagnosis of diabetes, the self-management requirements accompanying it, and/or difficulties in other areas of life, patients may decide to undertake behaviours that are detrimental to their well-being. For instance, they may adopt fixated attitudes towards their intake and weight. This paper explores the relationship between disordered eating habits, control and diabetes in those who are insulin dependent.

Prevalence and clinical manifestations of eating disorders in Austrian adolescents with type-1 diabetes

OBJECTIVES

To investigate prevalence and clinical manifestations of DSM-IV clinical eating disorders and subsyndromal eating problems among adolescents with type-1 diabetes.

METHOD

A clinical sample of 251 adolescents with type-1 diabetes was recruited from multiple centres. Of these adolescents, 199 (96 girls and 103 boys--79.3% participation rate) with a mean age of 14.1 years (SD: 2.6) were screened for eating disorders and then underwent DSM-IV-based clinical assessment of eating disorders by interview.

RESULTS

11.5% of the girls and none of the boys with type-1 diabetes had DSM-IV eating disorders, whereas 13.5% of the girls and 1% of the boys had subsyndromal problems of eating and shape. Girls with both type-1 diabetes and a clinical or subclinical eating disorder had a significantly higher body-mass index than those without eating problems.

CONCLUSION

This Austrian study supports cumulative international evidence that among youths with type-1 diabetes, adolescent girls and especially those having a higher body mass are particularly vulnerable for manifesting pathology of eating, weight and shape. Thus, this particular population requires screening of eating behaviour and relevant psychopathology, close monitoring, and psychosocial interventions through cooperative efforts of specialised centres.

Weight control practices and disordered eating behaviors among adolescent females and males with type 1 diabetes: associations with sociodemographics, weight concerns, familial factors, and metabolic outcomes

OBJECTIVE

This study examines the prevalence of specific weight control practices/disordered eating behaviors and associations with sociodemographic characteristics, BMI and weight perceptions, family functioning, and metabolic control among adolescent females and males with type 1 diabetes.

RESEARCH DESIGN AND METHODS

The study population included 70 adolescent females and 73 adolescent males with type 1 diabetes who completed the AHEAD (Assessing Health and Eating among Adolescents with Diabetes) survey. Data on BMI and glycosylated hemoglobin (HbA(1c)) were drawn from medical records.

RESULTS

Unhealthy weight control practices were reported by 37.9% of the females and by 15.9% of the males. Among the females, 10.3% reported skipping insulin and 7.4% reported taking less insulin to control their weight. Only one male reported doing either of these behaviors. Weight control/disordered eating behaviors were not associated with age, parental level of education, family structure, or race/ethnicity. Higher levels of weight dissatisfaction tended to be associated with unhealthy weight control/disordered eating; associations with BMI were inconsistent. Family cohesion was negatively associated with disordered eating among females (r = -0.52; P < 0.001) and males (r = -0.41; P < 0.001), but correlations with other measures of family environment (control, independence, and responsibility for diabetes management) were not significant. Correlations between disordered eating and HbA(1c) levels were significant among females (r = 0.33; P < 0.01) and males (r = 0.26; P < 0.05).

CONCLUSIONS

Special attention is needed for youth with weight concerns and those from less cohesive families to assist in the development of healthy diabetes management behaviors.

Links between psychological sense of control and disturbed eating behavior in women with diabetes mellitus. Implications for predictors of metabolic control

PURPOSE

Eating disturbances and aspects of psychological control are both repeatedly cited as significant correlates of metabolic control in diabetes mellitus (DM), yet such findings are typically discussed in separate literatures and have been criticized for overreliance on outdated constructs of psychological control when more complex means of analysis are available.

METHODS

Utilizing a multidimensional control inventory, this study investigates the relationship between eating disturbance and psychological sense of control, and assesses the utility of these two constructs in predicting metabolic control in 96 women recruited from a specialist diabetes clinic.

RESULTS

Despite significantly overlapping relationships between these two predictor variables and metabolic control, it is control specific to the domain of interpersonal relationships, along with eating disturbance in the form of bulimia/food preoccupation, that independently predicts level of metabolic control.

CONCLUSIONS

These findings have implications for the current form and content of psychological interventions in the management of DM.

Binge eating disorder: a review

Binge eating disorder (BED) is a new proposed eating disorder in the DSM-IV. BED is not a formal diagnosis within the DSM-IV, but in day-to-day clinical practice the diagnosis seems to be generally accepted. People with the BED-syndrome have binge eating episodes as do subjects with bulimia nervosa, but unlike the latter they do not engage in compensatory behaviours. Although the diagnosis BED was created with the obese in mind, obesity is not a criterion. This paper gives an overview of its epidemiology, characteristics, aetiology, criteria, course and treatment. BED seems to be highly prevalent among subjects seeking weight loss treatment (1.3-30.1%). Studies with compared BED, BN and obesity indicated that individuals with BED exhibit levels of psychopathology that fall somewhere between the high levels reported by individuals with BN and the low levels reported by obese individuals. Characteristics of BED seemed to bear a closer resemblance to those of BN than of those of obesity.A review of RCT's showed that presently cognitive behavioural treatment is the treatment of choice but interpersonal psychotherapy, self-help and SSRI's seem effective. The first aim of treatment should be the cessation of binge eating. Treatment of weight loss may be offered to those who are able to abstain from binge eating.

Mortality in concurrent type 1 diabetes and anorexia nervosa

OBJECTIVE

Previous studies in this field report early occurrence of diabetic complications, but excess mortality, though expectable, has not been reported. We combined information from earlier studies to estimate the mortality for this group of patients.

RESEARCH DESIGN AND METHODS

The observed mortality is analyzed using crude mortality rate (a percentage), standardized mortality ratio (SMR), incidence rate ratio, risk difference, and survival analysis.

RESULTS

After approximately 10 years of follow-up, 13 of 510 females with type 1 diabetes, 43 of 658 females with anorexia nervosa (AN), and 8 of 23 concurrent case subjects had died. Mortality rate was 2.2 (per 1,000 person-years) for type 1 diabetes, 7.3 for AN cases, and 34.6 for concurrent cases. Crude mortality rates were 2.5, 6.5, and 34.8%, respectively. SMR was 4.06 in type 1 diabetes, 8.86 in AN, and 14.5 in concurrent cases. Survival analysis indicated between-group differences in mortality.

CONCLUSIONS

Concurrent type 1 diabetes and AN is a rare but serious condition in females. All indexes of mortality evidence excess mortality in this preliminary study. Vigorous and well-directed treatment efforts seem vital for this subpopulation. Collaboration between diabetologists and eating disorder specialists is warranted. The implications of other eating disorders and subclinical eating disorders in diabetic populations need to be analyzed, especially because these conditions are more frequent than clinical eating disorders.

Comorbidity of diabetes mellitus and eating disorders: a follow-up study

OBJECTIVE

There is increasing evidence that the coexistence of diabetes and eating disorders (ED) leads to poor glycemic control and an increased risk of long-term complications.

METHODS

In a questionnaire- and interview-based study, a sample of 36 out of originally 38 (94.7%) diabetic patients with an ED (type-1: n=13, type-2: n=23) was assessed after a period of about 2 years in order to determine the course of EDs, body mass index (BMI), glycemic control, and psychiatric symptomatology.

RESULTS

Five patients (13.9%) of the total sample showed full remission for at least 12 consecutive weeks. Twenty-two patients (61.6%) showed no change in the diagnosis of the ED. Four patients (11.1%) shifted from subclinical to clinical EDs and five patients (13.9%) vice versa. Of the eight patients who went on to psychotherapy, only one patient (12.5%) showed full remission. Emotional distress of type-2 diabetics was considerably higher compared to type-1 diabetics, which was rather low at baseline. Except interpersonal distrust as one ED-related variable, no significant change of any psychological variable could be observed in the type-1 diabetic sample during follow-up. Of the 13 type-1 diabetic patients with an ED, five patients deliberately omitted insulin in order to lose weight. These patients showed a more serious psychopathology with regard to each measured psychological variable, a higher BMI, and worse metabolic control compared to those without insulin omission. Type-2 diabetics showed a significant increase in drive for thinness and body dissatisfaction. No considerable change could be observed with regard to BMI, glycemic control, and depressive and global psychiatric symptomatology in either diabetic subsample during follow-up.

CONCLUSION

EDs tended to persist over time with a considerable shift within the different types of EDs. Insulin-purging in type-1 diabetics was associated with enhanced psychopathology, higher BMI, and worse metabolic control. Both mean body mass and ED-related symptoms such as "drive for thinness" and "body dissatisfaction" increased in the average obese type-2 diabetic sample, illustrating the vicious circle of low self-esteem, enhanced restraint eating, and binge eating in weight control measures.

Epidemiology and mortality of eating disorders

Although considerable progress has been made over the past 2 decades in the field of eating-disorder epidemiology, there is room for improvement. Eating disorder diagnoses for children, need assessment, prospective longitudinal studies, studies of natural cause, treatment dose-effect studies, and bias are all areas that need careful consideration. Clinicians should consider establishing a Cochrane database for eating disorders. The mortality studies reviewed in this article are dominated by small, sparse, unbalanced data sets, and publication bias and bias caused by loss to follow-up limits the validity of the reported findings. Some methodologic advice is given in the hope that some of the more obvious pitfalls can be avoided in future research.

Relationship of weight and eating disorders in type 2 diabetic patients: a multicenter study

OBJECTIVE

Previous work suggested that the degree of psychiatric symptomatology evidenced in overweight individuals was related to the severity of binge eating problems and not related to the severity of overweight. In a multicenter study, we investigated the relationship between weight and eating disorders (EDs) in a sample of type 2 diabetic patients.

METHODS

Three hundred twenty-two patients with type 2 diabetes were stratified to various weight categories. Glycemic control, eating and body-related psychological problems, self-esteem, depressive, and general psychopathology of diaetic patients with and without an ED were compared.

RESULTS

Eighty-one percent of all type 2 diabetic patients were overweight or obese. Prevalence rates of EDs ranged from 6.5% to 9.0%. Binge eating disorder was the most diagnosed ED. There was a strong relationship between body mass index (BMI) and eating disturbance-related variables and a weak or no relationship between BMI and depression or general psychopathologic variables. Patients with an ED showed a greater psychopathology compared to patients without an ED. The diagnosis of an ED did not seem to have a specific influence on glycemic control.

CONCLUSIONS

Our results in a type 2 diabetic sample indicate that weight might have an impact on body and eating-related psychological distress in type 2 diabetic patients, but is of minor or no importance for depressive symptomatology, lower self-esteem, and general psychiatric symptomatology. Type 2 diabetic patients with an ED, however, suffer from considerable psychiatric symptomatology.