Disordered eating behaviors are more common among individuals with diabetes than in the general population, according to Lori Laffel, MD, MPH, chief of the section on pediatric, adolescent, and young adult diabetes at Joslin Diabetes Center and professor of pediatrics at Harvard Medical School in Boston.
Prevalence varies based on age and gender, with the highest rates likely among young women. In a recent longitudinal study of eating disorders in girls with type 1 diabetes, Patricia Colton, MD, deputy medical director of the eating disorders program at Toronto General Hospital, and assistant professor of psychiatry at the University of Toronto in Ontario, Canada, and colleagues found that 30% to 40% of women in the study were struggling with a significant eating problem from ages 19 to 24.1
Eating disorders also appear to be more prevalent in individuals with type 1 as compared with type 2 diabetes.
“This is likely associated [with] the ages of onset of these different conditions. Type 1 diabetes most often has its onset prior to peak ages of onset for eating disorders, while type 2 diabetes more commonly has its onset in adulthood,” said Dr. Colton.
Insulin Omission, Food Restriction as Weight Loss Strategies
According to Colton, the most common disordered eating behaviors in individuals with type 1 diabetes involve combinations of dietary restriction, binge eating and insulin restriction or omission. Cases of anorexia are also seen occasionally.
“It is very easy to skip insulin, or take less than what is needed, to control weight. Certainly these patients could have other eating disorder symptoms, such as binging and purging, using laxatives, [and] restricting food, but when it is as easy as skipping insulin, this seems to be the primary symptom,” said Marcia Meier, RN, CDE, diabetes educator at the Park Nicollet International Diabetes Center in Minneapolis, Minnesota.
In one study, Line Wisting, MA, of the regional eating disorders service, in the division of mental health and addiction at Oslo University Hospital in Oslo, Norway, and colleagues assessed the prevalence of disturbed eating behavior and insulin omission in a nationwide, population-based sample of adolescents with type 1 diabetes. The investigators found that disturbed eating behavior and insulin omission were common among adolescents with type 1 diabetes.2
“Given the frequency and severity of comorbid type 1 diabetes and disturbed eating behavior, routinely screening [for] disturbed eating behavior among young individuals with type 1 diabetes is crucial to secure early identification and subsequent intervention, especially among females aged 17 to 19 years,” said Wisting.
Signs, Symptoms and Predictive Factors
The main signs of eating disorders in diabetes are both behavioral and psychological. According to Colton, the behaviors include dieting, fasting and dietary restriction, binge eating and a range of compensatory behaviors. Psychological symptoms include overevaluating weight and shape in self-esteem as well as obsessional preoccupation with food, calories, weight and body shape.3
According to Ann Goebel-Fabbri, PhD, clinical psychologist at Joslin Diabetes Center and assistant professor of psychiatry at Harvard Medical School in Brookline, Massachusetts, in the case of insulin restriction, specific signs and symptoms may include elevated blood glucose, elevated HbA1c, rapid and unexplained weight loss and unexplained diabetic ketoacidosis. Symptoms can also include exhaustion, thirst, frequent urination, dehydration, mood changes and changes in eating patterns.
Researchers and practicing clinicians do not yet have a good understanding of who is at risk for developing an eating disorder in diabetes or what the protective factors might be. However, in a recent study, Margaret Powers, PhD, RD, clinical researcher at the Park Nicollet International Diabetes Center in Minneapolis, and colleagues evaluated nonsymptomatic factors influencing the development of eating disturbances in the at-risk populations.
“The burden of diabetes is highlighted in the five themes we identified pertinent to the dual diagnosis (feeling different, difficulty with control and coping, body image, feelings and quality of life). Four of the themes were relevant to eating disorder development,” said Powers.
“It is important for clinicians and patients to understand what these themes are and to actively address them in order to potentially stop the development of an eating disorder. The goal is early risk intervention for prevention, rather than intervention for treatment.”
Risks Tied to Eating Disorders in Diabetes
All eating disorders have clear health risks related to the condition. According to Colton, individuals who are significantly underweight are at greater risk for osteoporosis, infertility, dental damage and damage to the gastrointestinal system. Those who purge are at risk for potentially life-threatening electrolyte abnormalities and ECG disturbances, and those with significant weight gain from binge eating have higher risk for metabolic disorders associated with obesity.
In addition, in those with type 1 diabetes, even mild eating disorders are associated with an increased risk for short-term complications such as diabetic ketoacidosis and severe hypoglycemia, and long-term complications affecting retina, kidneys and peripheral nerves.
“These are likely related to chronically high blood sugar levels caused by insulin misuse and omission as well as difficulty regulating blood sugar levels when food intake is chaotic. Unfortunately, risk of death also appears to be elevated in those with type 1 diabetes who are also struggling with an eating disorder,” said Colton.
In an 11-year follow-up study of women with type 1 diabetes, Goebel-Fabbri and colleagues evaluated whether insulin restriction increases morbidity and mortality in women with type 1 diabetes.4
“We found that those who identified themselves as restricting insulin had three times the risk of mortality (in that 11-year period) than those who did not restrict. Those who restricted also had greater number of diabetes complications and at an earlier age and shorter duration of disease,” said Goebel-Fabbri.
Multidisciplinary Approach to Treatment May Be Best
According to Colton, there is currently little evidence to guide management and treatment of eating disorders in people with diabetes. Laffel believes it is critical to take a multidisciplinary approach, with coordination between a psychologist, endocrinologist and other medical practitioners.
“Clinicians need to have awareness about disordered eating in diabetes and understand that it can be common. Physicians should be looking for patients who have consistently high blood sugar levels and high hemoglobin A1C that are concerned about body image and body weight, even across the spectrum of weight status,” said Laffel.
- Colton PA et al. Diabetes Care. 2015;doi:10.2337/dc14-2646.
- Wisting L et al. Diabetes Care. 2013;36:3382-3387.
- Powers MA et al. J Health Psychol. 2015;doi:10.1177/1359105315589799.
- Goebel-Fabbri et al. Diabetes Care. 2008;31:415-419.