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Eating Disorders and Disordered Eating Symptoms in Adolescent Type 1’s

Children and teenagers with type 1 diabetes are more likely to have eating disorders.

Type 1 diabetes accounts for 10 – 15% of all cases of diabetes that are diagnosed annually and its incidence increases at a rate of 3% per year worldwide. Type 1 diabetes occurs due to the partial or complete destruction of pancreatic β-cells resulting in chronic lack of insulin, severe metabolic problems and emergence of hyperglycemia. Healthcare providers often discuss the macrovascular and microvascular complications that patients with diabetes may experience. However, psychiatric conditions such as depression, anxiety, and eating disorders are also commonly seen in adolescents, but are seldom discussed. Eating problems in adolescents with type 1 diabetes can be divided into two groups; diagnosed eating disorders (EDs) and disordered eating symptoms (DES). Diagnosed eating disorders include anorexia nervosa, bulimia nervosa, binge-eating disorder, pica and rumination, whereas disordered eating symptoms include behaviors for dieting and weight loss such as excessive exercise, intentional binging and purging, laxative and diuretic use. This review aimed to assess current knowledge and clinical relevance of eating disorders in adolescents with type 1 diabetes, as well as preventative and therapeutic interventions.

There have been several studies evaluating the prevalence of EDs and DES in adolescents, and researchers have found that people with type 1 diabetes are more prone to developing eating problems. A meta-analysis involving six studies on disordered eating found that approximately 7% of subjects with type 1 diabetes were diagnosed with EDs; this is in comparison to 2.8% of the control subjects. Several prospective studies have identified factors that increase the risk of adolescents with type 1 diabetes developing psychiatric problems leading to EDs and DES. Age, sex, BMI, body perception and family support all play a major role in this increased risk. Females are twice as likely as males to develop EDs or DES, and children between the ages of 7-18 years old are also at an increased risk. One study found that 10.3% of adolescent girls skipped insulin doses and that 7.4% intentionally took less insulin to lose weight, this is compared to only 1.4% of male patients. In adolescents with type 1 diabetes large fluctuations in weight are common, with most patients seeing a decrease in weight when first diagnosed and most gaining weight after initiation of insulin therapy. Studies have shown that adolescents with type 1 diabetes have higher BMIs in comparison to healthy adolescents (26.3 +/- 2.6 kg/m2 vs. 23.6 +/- 3.8 kg/m2; p < 0.05). The occurrence of higher weight was almost entirely due to increased fat mass in the upper part of the body and was significantly correlated to diabetes control. Body dissatisfaction is a main reason for the development of EDs and DES. Researchers assessed 79 male and female patients with type 1 diabetes using several validated questionnaires designed specifically to evaluate eating disorders, self-esteem, anxiety and overall quality of life. Patients who were unhappy with their current weight were more likely to have anxiety and a decreased quality of life. There was a significant association between the desire to lose weight and the emergence of certain eating behaviors. Approximately 48.6% of individuals who wanted to lose weight reported self-induced vomiting and laxative use, this was in comparison to 2.3% of individuals who were satisfied with their current weight.

Early detection and diagnosis is key to improving patient outcomes. There are several signs indicating possible ED or DES including: poor glycemic control, recurrent hypoglycemic episodes, systematic calculations of caloric values, weighing foods, refusal to be weighed, concern for appearance and a tendency towards vegetarianism. The first sign that should alert healthcare providers to the possibility of EDs or DES is poor glycemic control. Researchers found that mean HbA1c values were significantly higher (11.1% +/- 1.2%) in the highly-disordered eating group than those with moderate-disordered eating (8.9% +/- 1.7%) or non-disordered eating (8.7% +/- 1.6%). Diagnosis is difficult and children and teenagers are often embarrassed, ashamed or afraid of repercussions for disclosing any unhealthy eating habits. To ensure the best care for adolescents with type 1 diabetes healthcare teams should be multidisciplinary and include a pediatric diabetes expert, dietician and psychologist. Interventions aimed to increase self-esteem, body acceptance and educating the entire family on diabetes management are a few strategies to help reduce the risk of a child or teenager developing an eating disorder.

Practice Pearls:

  • Girls with type 1 diabetes between the ages of 7-18 years old are most likely to be afflicted with an eating disorder.
  • Poor glycemic control, recurrent hypoglycemic episodes, and systematically weighing and calculating caloric values of meals are all warning signs of disordered eating.
  • Promoting positive body image, healthy eating and exercising, and an open dialogue with adolescent patients may help prevent development of disordered eating in type 1 diabetes patients.  

Reference:

Toni, Giada, et al. “Eating Disorders and Disordered Eating Symptoms in Adolescents with Type 1 Diabetes.” Nutrients 9.8 (2017): 906.

Jessica Lambert, University of South Florida College of Pharmacy, Doctor of Pharmacy Candidate 2018