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Psychosocial care in diabetes


Disordered eating

Eating disorders in girls and women with type 1 diabetes: A longitudinal study of prevalence, onset, remission, and recurrence

This study describes the longitudinal course of disturbed eating behavior and eating disorders in a cohort of females with type 1 diabetes over 14 years.

Summary points
  • Teenage girls and women with type 1 diabetes are at significantly increased risk of disturbed eating behaviors, such as dieting, fasting, binge-eating and a range of other compensatory and purging behaviors, compared with their non-diabetic peers; disturbed eating behaviors can interfere with diabetes management.
  • Deliberately under-dosing or omitting insulin to induce hyperglycemia and loss of glucose in the urine to control weight is a purging behavior unique to individuals with type 1 diabetes; it is one of the mechanisms underlying the association between disturbed eating behavior and eating disorders and poor metabolic control.
  • A total of 126 girls with type 1 diabetes (disease duration of >6 months) aged 9 to 13 years (mean age: 11.8±1.5 years) were recruited at the Diabetes Clinic at The Hospital for Sick Children in Toronto between 1998 and 2001 and followed for 14 years.
  • Assessments were performed at baseline (time 1) and 1 (time 2), 2 (time 3), 3 (time 4), 5 (time 5), 8–10 (time 6) and 10–14 (time 7) years after time 1; at times 1–4, the children’s eating disorder examination (cEDE) was used, and at times 5–7, the eating disorder examination (EDE) was used.
  • At time 6 (age range: 17.3–23.2 years), 19.8% (16/81) suffered from a full-syndrome or sub-threshold eating disorder.
  • At time 7 (age range: 19.2–27.8 years), disturbed eating behavior was reported by 59.2% (42/71) of participants.
  • At time 6, HbA1c was significantly higher among women with a current eating disorder than in those without (10.06±1.5% [86±14 mmol/mol] vs 8.7±1.6% [72 ± 15 mmol/mol]; t=2.2, df=52, P=0.04, d=0.83).
  • At time 7, a trend towards higher HbA1c among those with an eating disorder compared with those without (9.0 ± 1.8% [75±17 mmol/mol] vs 8.2±1.3% [66±12 mmol/mol]; t=1.9, df=51, P=0.07, d=0.51).
  • Estimates of the cumulative probability of disturbed eating behavior onset remained reliable up to age 23 years; 79% experienced onset of disturbed eating behavior by this point.
  • Estimates of the cumulative probability of eating disorder onset remained reliable up to age 25 years; 60% experienced onset of an eating disorder by this point.
  • Both disturbed eating behavior and eating disorders tended to be persistent, with a mean time from observed onset to detected remission of 6.0 and 4.3 years, respectively, and significant estimated risk of recurrence.
  • Disordered eating is a common and serious concern among girls and young women with type 1 diabetes.

Colton PA et al. Diabetes Care 2015; 38: 1212. doi: 10.2337/dc14-2646

Treatment outcome of patients with comorbid type 1 diabetes and eating disorders

This study compared treatment outcomes, dropouts, eating disorder psychopathology and personality characteristics in individuals with eating disorders with comorbid type 1 diabetes and those without.

Summary points
  • Overall, 40 adult female patients diagnosed with eating disorders according to the DSM-IV were recruited at the Eating Disorder Unit of the Bellvitge Hospital (Barcelona, Spain) between April 1999 and June 2012, 20 with comorbid type 1 diabetes (disease duration >6 months; mean age: 25.3 years) and 20 controls (mean age: 28.0 years) matched for socio-demographic variables.
  • Patients received the following treatments:
    • 16 sessions of cognitive-behavioral therapy for those with bulimia nervosa, binge eating disorder and eating disorder not otherwise specified;
    • 3 months daytime hospitalization for anorexia nervosa patients.
  • Assessments included semi-structured interviews conducted by experienced psychologists and psychiatrists, a battery of psychological questionnaires, including the Temperament and Character Inventory–revised (TCI-R) and the Eating Disorders Inventory-2 (EDI-2) and a visual analogue scale to assess the motivational stage of change.
    • In patients with type 1 diabetes, HbA1c measured nearest to the interview was used as an indicator of glycemic control.
  • Age of onset of eating disorder was 19.5 years (SD=7.4) for patients with type 1 diabetes and 19.4 (SD=7.5) for controls.
  • The majority (90%, n=18) of patients with type 1 diabetes acknowledged skipping or reducing insulin doses to control weight.
  • Patients with type 1 diabetes were significantly less likely than controls to self-harm (p<0.012; d:1.03), have suicidal ideation (p<0.030; d:0.80) and suicidal behavior (p <0.039; d:0.79).
  • Patients with type 1 diabetes scored significantly lower on motivation to change and level of consciousness about their eating disorder, and had significantly lower persistence compared with controls.
  • Three quarters of patients in the control group (n=15) showed partial or full remission compared with 50% (n=10) of those with type 1 diabetes.
  • The number of dropouts was higher among patients with type 1 diabetes compared with controls and they stopped treatment significantly earlier (χ2=4.50, df=1, p=0.034).
  • Low levels of motivation to change and insulin abuse in patients with type 1 diabetes and eating disorders may suggest that in devising a treatment strategy aimed at this population, clinicians should consider the individual’s personality and role of insulin abuse in determining the appropriate intervention.

Custal N et al. BMC Psychiatry 2014; 14: 140. doi: 10.1186/1471-244X-14-140

Contents

Back to collection

  1. Editorial
  2. Overview
  3. Adherence
  4. Diabetes distress and psychological comorbidities
  5. Disordered eating
  6. Quality of life
  7. Pyschosocial interventions
  8. Self management strategies

  9. Supplementary resource