KEYSTONE, COLO. — Significant predictors of the onset of disturbed eating behavior within the next several years in girls with type 1 diabetes include concerns with weight and shape, a higher body mass index, depressive symptoms, and poor self-esteem—both globally and specifically with regard to physical appearance, according to a new prospective study.
These are the factors to look out for in clinical practice. Collectively they explained 48% of the variance between young adolescent girls with diabetes who went on to manifest disturbed eating behavior (DEB) within the next 5 years and those who didn't, Dr. Denis Daneman said at a conference on the management of diabetes in youth.
The study findings raise the possibility that early interventions focused on helping girls with diabetes develop positive feelings about themselves might protect against later development of DEB.
But this hypothesis requires testing, particularly in light of the fact that no successful strategies for the prevention of eating disorders in adolescents and young adults with type 1 diabetes have been reported to date. Moreover, treatment of eating disorders in this population has proved extremely difficult, much more so than in patients without diabetes, according to Dr. Daneman, professor and chair of the department of pediatrics at the University of Toronto and pediatrician-in-chief at the Hospital for Sick Children.
The prospective study involved 126 girls with type 1 diabetes enrolled at ages 9-13 years at the pediatric hospital and followed for 5 years. They were interviewed annually using the validated, semistructured Eating Disorder Examination. The study was designed to identify predictors of DEB by following girls as they moved into the peak years of DEB onset, which is ages 15-25, the pediatrician said.
At entry, 25 girls had DEB as defined by dieting for weight control, self-induced vomiting, binge eating, or using insulin omission, laxatives, intense exercise, or diuretics for weight control. Another 45 girls developed DEB during follow-up (Diabetes Care 2008 July 15 [doi:10.2337/dc08-0333
Eating disorders are a huge problem among girls and young women with type 1 diabetes, said Dr. Daneman, who has cowritten nearly two dozen publications on the topic. His own studies, as well as others conducted in Scandinavia, the United Kingdom, France, and the United States, indicate that 10% of girls with type 1 diabetes in their midteens meet formal DSM-IV criteria for an eating disorder and another 14% have subthreshold eating disorders—that is, their DEB doesn't fulfill DSM-IV criteria for an eating disorder but nonetheless has important clinical consequences, including poor control of blood glucose and early onset of diabetes complications.
The two full-blown DSM-IV eating disorders associated with type 1 diabetes are bulimia nervosa and eating disorder not otherwise specified (EDNOS). Anorexia nervosa isn't part of the picture. “When type 1 diabetes and anorexia nervosa occur together, it's a chance occurrence,” Dr. Daneman said at the conference, which was cosponsored by the Barbara Davis Center for Childhood Diabetes, the University of Colorado, and the Children's Diabetes Foundation at Denver.
Dr. Daneman views it as a major failing of the eating disorders section of DSM-IV that insulin manipulation for the purpose of weight control isn't listed as a major diagnostic criterion. But he indicated he isn't losing any sleep over the omission.
“The DSM criteria are largely non-evidence-based. Compared to the rest of medicine, which is increasingly evidence-based, psychiatry is much more consensus-based. The DSM is put together by a small group of like-minded people,” he said.
'When type 1 diabetes and anorexia nervosa occur together, it's a chance occurrence.' DR. DANEMAN