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Higher Risk of Disordered Eating Behavior Follows Young Women with Type 1 Diabetes into Adulthood

The risk of eating disorders and disordered eating behavior is higher for female adolescents with type 1 diabetes than their non-diabetic counterparts, and remains higher well into adulthood…

A recently study followed 126 adolescent girls with type 1 diabetes treated at the diabetes center of the Hospital for Sick Children in Toronto over 14 years. The mean age of participants at the start of the study was 11.8 ± 1.5 years, and 23.7 ± 2.1 years at the conclusion. The young women were interviewed at the start of the study and at six more intervals over the subsequent 14 years to determine the incidence of eating disorders (ED), disordered eating behavior (DEB), and subclinical eating disorders. EDs were diagnosed according to DSM-IV-TR guidelines. DEBs were characterized by behaviors over the previous 28 days such as excessive dieting, binge-eating, self-induced vomiting, and other purging behaviors including laxative and diet pill abuse, excessive exercise, and insulin omission. Subclinical EDs were determined by incidences of binging and various purging behaviors, or incidences of negative self-evaluation primarily influenced by weight or body image coupled with excessive calorie restriction or excessive exercise for weight control over the previous three months.

The study found that diabetic females were at a higher risk for disordered eating at all ages included in the study than their non-diabetic peers. For the general population, “bulimic symptoms most commonly emerge during mid-adolescence, with peak bulimia nervosa onset in late adolescence. Rates of dieting and other DEB generally increase from adolescence into early adulthood, but decrease by mid-adulthood. Of concern, in this study the incidence of DEB and EDs remained high, even during follow-up well into young adulthood, and the expected decrease in the incidence and frequency of eating disturbances has not yet emerged in this cohort,” according to the study’s authors. At the sixth follow-up (time 6), participant ages ranged from 17.3 to 23.2 years old, and 33.3% were characterized with ED or DEB. At the seventh follow-up (time 7), participants ranged in age from 19.2 to 27.8 years, and 59.2% were characterized with some form of disordered eating. In addition, disordered eating appeared to be persistent, with high rates of re-emersion after remission, and long-lasting, with the mean length of time from onset to remission at six years for women with type 1 diabetes.

The increase in DEB in older women of the study is due largely to a method of purging that is not available to non-diabetic women: insulin omission. Removing DEB diagnoses due to insulin omission at time 6 reduced the rate of DEB from 33.3% to 30.8%, but by time 7, removing incidents of DEB due to insulin omission changes the prevalence from 59.2% to 35.2%. “This dangerous method of purging directly compromises metabolic control and confers both short-term and long-term medical risk,” Patricia A. Colton and colleagues write. Evidence of this increased risk is seen in A1c levels that tended to be higher in study participants with EDs than those without (10.0% ± 1.5% vs 8.2% ± 1.6%; P = 0.04 at time 6, and 9.0% ± 1.8% vs 8.2% ± 1.3%; P = 0.07 at time 7).

By time 7, 27% of study participants admitted to using insulin omission as a method of weight control. The authors conclude that clinicians need to be aware of the increased risk of disordered eating among their Type 1 female patients well into adulthood, and “that eating disturbances in this population may be often persistent and recurring, rather than mild and transient.” The health risks associated with insulin omission warrant diligent screening and treatment efforts for this population.

Practice Pearls:

  • Adolescent girls and young women with Type 1 diabetes are at a higher risk of disordered eating than their non-diabetic counterparts.
  • Insulin omission is a dangerous method of weight control frequently used by young women.
  • Increased screening and treatment efforts for disordered eating among diabetic women can decrease short and long-term consequences of hyperglycemia.

Colton PA, Olmsted MP, Daneman D, Farquhar JC, Wong H, Muskat S, Rodin GM. Eating disorders in girls and women with Type 1 diabetes: a longitudinal study of prevalence, onset, remission, and recurrence. Diabetes Care. 2015; 38: 1212-1217.