MONTREAL – Eating disorders occur twice as often in adolescent girls and young women with type 1 diabetes mellitus, compared with their nondiabetic peers, and prepubertal diabetic girls should be screened for these disorders routinely, experts said at an international conference sponsored by the Academy for Eating Disorders.
Studies show that full-syndrome eating disorders are present in 10%, and subthreshold disorders in 14%, of adolescent girls with diabetes, compared with 4% and 8% respectively in healthy age-matched controls, said Patricia Colton, M.D., of the University of Toronto. Her own work in diabetic girls aged 9–14 years found an 8% prevalence of subthreshold eating disorders, compared with 1% in nondiabetic controls (Diabetes Care 2004;27:1654–9).
Such disturbed eating has been linked with poor metabolic control and increased rates of diabetes-related complications–in particular, a threefold risk of diabetic retinopathy, she said. Thus, early detection and treatment of eating disorders can have long-term benefits.
It has been suggested that a collection of multiple, interacting factors contributes to the development of eating disorders in patients with diabetes, Dr. Colton said.
Before their diagnosis, many diabetic girls tend to lose weight, which can often return to above baseline after treatment begins. Insulin therapy can cause weight gain, particularly during puberty, and episodes of hypoglycemia, so common in diabetes, can trigger binge eating, which has been reported in 45%–80% of women with diabetes.
“Low blood sugar is an incredibly strong biological trigger to eat,” she noted.
All these factors may contribute to feelings of body dissatisfaction and efforts to control weight, including one method unique to diabetes–the omission of insulin therapy, reported by 12%–40% of this population.
But overlying these concerns are such daily management concerns as self-monitoring, dietary restraint, and preoccupation with food, which can give rise to issues of control and rebellion, especially in the adolescent population, she said.
“Dealing with a chronic medical condition can have significant effects on the child and the family. Depression and anxiety disorders are doubled or tripled in individuals with diabetes,” she said, adding that depressive symptoms have also been linked with hyperglycemia.
Established treatments for eating disorders appear effective in patients with diabetes, but tailoring these treatments more closely to diabetes-specific issues may enhance their value for this population, said Marion Olmsted, Ph.D., who is also with the University of Toronto and is director of ambulatory care for eating disorders at the University Health Network, Toronto General Hospital.
Psychoeducational interventions can improve weight and body-shape attitudes in teenaged girls who do not have full-blown eating disorders. Cognitive-behavioral strategies can be used to address issues such as blood sugar monitoring, insulin underdosing or omission, and eating patterns. And psychotherapy can address issues of rebellion, control, anger, and depression. More intensive approaches, such as day hospital treatment, are required in some cases, she said. Just as family dysfunction is recognized as a risk factor for eating disorders in nondiabetic girls, this dynamic can be a powerful factor in the diabetic population, she explained.
Research by Dr. Olmsted and her colleagues at the University of Toronto has shown that diabetic girls with eating disturbances report less support, poorer communication, and less trust in their relationships with their parents than do diabetic girls without eating disturbances (J. Psychosom. Res. 1998;44:479–90).
In one study, mothers who were videotaped interacting with their daughters who had diabetes and eating disturbances showed less empathy, affective engagement, and support for their child's age-appropriate autonomy, compared with mothers of diabetic daughters without eating disturbances (J. Consult Clin. Psychol. 2001;69:950–8).
“Mothers of diabetic girls with eating disturbances appear to be less able to balance their teenage daughters' complementary needs for independence and supportive guidance,” Dr. Olmsted and her associates said in a literature review (J. Psychosom. Res. 2002;53:943–9).
Evidence shows that as adolescence progresses, behaviors such as insulin omission and binge eating become more common in young women, they reported.
“Indeed, [these behaviors] may account for the increased frequency of diabetic ketoacidosis and hospitalization for this complication in teenage girls, compared to teenage boys with diabetes,” they said in the review.