In the JournalsPerspective

Eating disorders worsen health, quality of life for teens with diabetes

Adolescents with diabetes and disordered eating behaviors may be more likely to have higher levels of HbA1c and more depressive symptoms in combination with lower reported quality of life compared with those without disordered eating behaviors, according to findings published in Diabetes Care.

“The etiology of [disordered eating behaviors] in diabetes seems to be multifactorial,” Catherine Pihoker, MD, professor and division chief in the department of pediatrics at the University of Washington in Seattle, and colleagues wrote. “Behaviors and attitudes that are important components of diabetes management, such as dietary restraint and counting carbohydrates, may place an unhealthy emphasis on food intake that results in dysregulated eating patterns.”

Pihoker and colleagues conducted analysis based on data from the SEARCH for Diabetes in Youth study, which recruited children, adolescents and young adults who were diagnosed with diabetes before age 20 years at five sites in the United States. For the study by Pihoker and colleagues, all participants were diagnosed after age 10 years, between 2002 and 2008. There were 2,156 participants with type 1 diabetes (mean age, 17.7 years; 50% female) and 149 with type 2 diabetes (mean age, 21.8 years; 64% female).

A 16-item questionnaire was used to determine the degree to which a participant had disordered eating behaviors, with a score of 20 established as the minimum needed to confirm the condition. Participants also completed the Center for Epidemiological Studies Depression Scale and the Pediatric Quality of Life Inventory scale to establish measures of depressive symptoms and quality of life, respectively.

The researchers found that 21.2% of the participants with type 1 diabetes and 50.3% of those with type 2 diabetes had disordered eating behaviors, with the highest percentage in those aged 15 to 19 years in both groups (24.9% and 67.8%, respectively). The researchers further noted a higher proportion of girls in the group of participants with type 1 diabetes and disordered eating behaviors (71.2%) and the group with type 2 diabetes and disordered eating behaviors (68%).

BMI z scores were higher for participants with disordered eating behaviors than those without them, including those who reported behaviors such as insulin restriction (P = .03), skipping meals (P < .01), binge eating (P < .01) and self-induced vomiting (P = .04), according to the study. Insulin sensitivity scores were lower for those with disordered eating behaviors, including insulin restriction, skipping meals, binge eating and self-induced vomiting (P < .01 for each comparison).

Disordered eating behaviors were linked to higher HbA1c levels for participants with type 1 diabetes and those with type 2 diabetes (P < .001 for each comparison) compared with those who did not have such behaviors, the researchers wrote. Participants with type 1 diabetes or type 2 diabetes and disordered eating behaviors also had higher scores for depressive symptoms (P < .01) and lower scores for quality of life (P < .01) than those without.

“Youth and young adults who are overweight or obese may desire to lose weight, which may result in a negative body image, dieting and [disordered eating behaviors],” the researchers wrote. “Overweight and obese youth and young adults with diabetes are commonly counseled to reduce their weight, at which time health care professionals should query for, identify and address [disordered eating behaviors].” – by Phil Neuffer

Disclosures: The authors report no relevant financial disclosures.

Adolescents with diabetes and disordered eating behaviors may be more likely to have higher levels of HbA1c and more depressive symptoms in combination with lower reported quality of life compared with those without disordered eating behaviors, according to findings published in Diabetes Care.

“The etiology of [disordered eating behaviors] in diabetes seems to be multifactorial,” Catherine Pihoker, MD, professor and division chief in the department of pediatrics at the University of Washington in Seattle, and colleagues wrote. “Behaviors and attitudes that are important components of diabetes management, such as dietary restraint and counting carbohydrates, may place an unhealthy emphasis on food intake that results in dysregulated eating patterns.”

Pihoker and colleagues conducted analysis based on data from the SEARCH for Diabetes in Youth study, which recruited children, adolescents and young adults who were diagnosed with diabetes before age 20 years at five sites in the United States. For the study by Pihoker and colleagues, all participants were diagnosed after age 10 years, between 2002 and 2008. There were 2,156 participants with type 1 diabetes (mean age, 17.7 years; 50% female) and 149 with type 2 diabetes (mean age, 21.8 years; 64% female).

A 16-item questionnaire was used to determine the degree to which a participant had disordered eating behaviors, with a score of 20 established as the minimum needed to confirm the condition. Participants also completed the Center for Epidemiological Studies Depression Scale and the Pediatric Quality of Life Inventory scale to establish measures of depressive symptoms and quality of life, respectively.

The researchers found that 21.2% of the participants with type 1 diabetes and 50.3% of those with type 2 diabetes had disordered eating behaviors, with the highest percentage in those aged 15 to 19 years in both groups (24.9% and 67.8%, respectively). The researchers further noted a higher proportion of girls in the group of participants with type 1 diabetes and disordered eating behaviors (71.2%) and the group with type 2 diabetes and disordered eating behaviors (68%).

BMI z scores were higher for participants with disordered eating behaviors than those without them, including those who reported behaviors such as insulin restriction (P = .03), skipping meals (P < .01), binge eating (P < .01) and self-induced vomiting (P = .04), according to the study. Insulin sensitivity scores were lower for those with disordered eating behaviors, including insulin restriction, skipping meals, binge eating and self-induced vomiting (P < .01 for each comparison).

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Disordered eating behaviors were linked to higher HbA1c levels for participants with type 1 diabetes and those with type 2 diabetes (P < .001 for each comparison) compared with those who did not have such behaviors, the researchers wrote. Participants with type 1 diabetes or type 2 diabetes and disordered eating behaviors also had higher scores for depressive symptoms (P < .01) and lower scores for quality of life (P < .01) than those without.

“Youth and young adults who are overweight or obese may desire to lose weight, which may result in a negative body image, dieting and [disordered eating behaviors],” the researchers wrote. “Overweight and obese youth and young adults with diabetes are commonly counseled to reduce their weight, at which time health care professionals should query for, identify and address [disordered eating behaviors].” – by Phil Neuffer

Disclosures: The authors report no relevant financial disclosures.

    Perspective

    This large-scale study of disordered eating behaviors included male and female adolescents and young adults from diverse backgrounds as well as both type 1 and type 2 diabetes being treated with insulin.

    High rates of disordered eating were reported in youths with both types of diabetes (21% in type 1 and 50% in type 2) and increased with age. Rates were higher in girls than boys with type 1 diabetes. Equal rates were reported in boys and girls with type 2 diabetes, more often binge eating. Those with disordered eating reported more symptoms of depression and worse quality of life. In type 1 diabetes, disordered eating was associated with a two-fold increase in episodes of diabetic ketoacidosis. Eighteen percent of participants with type 1 and 23% with type 2 diabetes reported restricting insulin to purge calories through glycosuria. However, in type 1 diabetes, intentional insulin restriction, skipping meals, or binge eating were strongly associated with higher BMI and decreased insulin sensitivity. The authors speculate that these disordered eating behaviors may contribute to dysregulation of eating behavior and paradoxically contribute to weight gain.

    These findings illustrate several things that endocrinologists should understand about disordered eating. Including boys in the research was important, because boys also report disordered eating behaviors though at lower rates than girls. In fact, in youths with type 2 diabetes, both genders appear to equally struggle with disordered eating, especially binge eating. Though not at the severity of diagnosable eating disorders, these behaviors contribute to increased frequency of DKA in youths with type 1 diabetes. Lastly, disordered eating was associated with higher weight and related to serious medical and emotional sequelae.

    This study challenges the stereotype of disordered eating primarily occurring in underweight white girls. Endocrinology teams should be encouraged to routinely screen for these problems in their patients and identify mental health providers with whom they can collaborate. The earlier these behaviors can be identified, the more likely that full-blown eating disorders might be avoided.

    • Ann Goebel-Fabbri, PhD
    • Clinical Psychologist, Boston

    Disclosures: Goebel-Fabbri reports no relevant financial disclosures.