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Associated Risk Factors in the Development of Bulimia Symptoms in Adolescents with Type 1 Diabetes

In addition to psychosocial risk factors, disease related factors may also be contributing to bulimic symptoms.

Adolescents with type 1 diabetes have an increased risk of developing eating disorders, such as bulimia. In addition to traditional bulimia symptoms, this patient population is also known to exhibit behaviors that deliberately cause hyperglycemia and glycosuria. Restricting or omitting the use of their insulin results in a negative impact on their clinical outcomes as well as place these patients at risk for developing complications of their disease. Previous studies have established a role of psychosocial risk factors (body image dissatisfaction and depression) contributing to the development of eating disorders. However, it has been theorized in the modified dual-pathway model, that physiological processes and treatment related factors from their disease (hunger, dysregulations in satiety, hormonal deficits and continuous fluctuations in blood glucose) may also play an important role in this patient population.

A cross-sectional pilot study was conducted to evaluate whether disease and treatment related factors in conjunction with psychosocial risk factors contributed to the development of bulimia symptoms in adolescents with type 1 diabetes. The study recruited 43 adolescents on a multiple daily injection regimen before converting them to an insulin pump. Within 10 days of the conversion to an insulin pump, self-reported variables of bulimic symptoms, depression, hunger, satiety and eating behaviors were gathered using the diabetes treatment and satiety scale, the children’s depression inventory, youth risk behavior study, body mass index, A1C and eating disorder inventory-III bulimia subscale. These variables were then evaluated using a hierarchical multiple regression.

Descriptive statistics were analyzed using a one-way ANOVA and t tests. Female participants were shown to have higher body image dissatisfaction compared to males (p < 0.05), placing this demographic at higher risk for developing bulimia symptoms. Using a bivariate correlation, the researchers also found that there was a statistical difference in the correlation of bulimic symptoms with uncontrolled hunger (p < 0.05), body image dissatisfaction, (p < 0.05) and depression (p < 0.05). There was also a statistical difference in the correlation of body image dissatisfaction with depression (p < 0.01). Using a three-step multiple regression analyses, the third step of the model indicated a statistical difference between depression and uncontrolled hunger in bulimia scores (p < 0.1). This showed an association of the combination of disease and treatment related factors with psychosocial factors in regards to bulimia symptoms experienced in these participants.

Although these findings support the hypothesis of the dual-pathway model, it is important to note that this is a pilot study with a small sample size. The study did not control the differences in insulin doses and administration. The self-reported measures also did not take into account the misuse of insulin by restriction or omission. Future prospective studies will be necessary to establish causation of disease and treatment-related factors in the development of bulimia in adolescents with type 1 diabetes. This study is clinically important because it suggests a multidisciplinary approach may be necessary to address and treat all contributing factors of bulimia symptoms, including factors caused by the disease itself.

Practice Pearls:

  • Adolescent patients with the development of bulimic symptoms are at higher risk for disease-related complications.
  • Disease-related factors, such as hunger and satiety, may play a role in the development of bulimic symptoms in adolescents with type 1 diabetes.
  • This study suggests a multidisciplinary approach in the treatment of both psychosocial and disease-related factors may improve clinical outcomes in this patient population.

References:

Peterson C, Young-Hyman, D, Fischer S, et al. Examination of Psychosocial and Physiological Risk for Bulimic Symptoms in Youth with Type 1 Diabetes Transitioning to an Insulin Pump: A Pilot Study. Journal of Pediatric Psychology. 2017. Epub 2017/05/23. doi: 10.1093/jpepsy/jsx084.

Joanna Martinez-Mendez, PharmD Candidate 2018, Lake Erie College of Osteopathic Medicine School of Pharmacy: FL Campus