Disordered Eating in Type 1 Diabetes: Insulin Omission and Diabulimia

US Pharm. 2012;37(5):Epub.

It is estimated that 14% of girls and 7% of boys aged 9 to 14 years exhibit behavioral patterns reflective of eating disorders.¹ The Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition) (DSM-IV), further divides eating disorders into three distinct diagnoses—anorexia, bulimia, and eating disorder not otherwise specified—based on clinical characteristics, behavioral patterns, and symptoms.² Unfortunately, many individuals exhibiting disordered eating patterns fail to seek appropriate treatment, leading to a multitude of complications affecting all organ systems. As a result, eating disorders carry the highest mortality rate—approaching 20%—of all psychiatric illnesses.³ Young adults with diabetes are at increased risk for developing psychiatric comorbidities, including eating disorders, because of the complex nature of chronic disease management as well as the effects of chronic disease on psychosocial functioning.⁴ The presence of psychiatric comorbidity can lead to suboptimal glycemic management and disease.⁴ This article will discuss the dynamic nature of eating disorders in type 1 diabetes mellitus (T1DM) patients, including clinical features, consequences, and management.

T1DM and Adolescence

Adolescence is a time of psychological, physiological, and emotional transition that is characterized by self-discovery involving peer pressure, family struggle, and a search for identity. During this transition, adolescents strive for both peer acceptance and self-acceptance.⁵ Chronic illness, such as diabetes, may negatively affect an adolescent’s individuation.⁶ From a clinical perspective, adolescence presents psychological and physiological challenges for disease treatment.⁵ In addition to the biological factors that complicate optimal glycemic management in adolescence, including increased growth hormone secretion, elaborate pubertal nutrient requirements, and puberty-provoked insulin resistance, youths with T1DM may exhibit specific disease-related considerations that complicate proper disease management.^7-9 Multiple barriers have been identified that influence the self-management of T1DM in adolescent patients, including embarrassment about the diagnosis, rebellion against authority, negative peer relationships, schoolmates’ lack of awareness about the disease, family pressure, and frustration with life changes.¹⁰

Although adolescence is typically a time when youths strive for independence, a strong family support system becomes increasingly important for optimal glycemic control in those with T1DM. In one study, a supportive family unit was associated with regimen adherence in young children diagnosed with T1DM, and another study found that familial conflict worsened overall outcomes.^11,12 Family support has been cited as the most important factor in preventing the onset of psychiatric disease in children and adolescents with T1DM, as well as in helping them adjust to living with a chronic medical condition.⁶ Parents of an adolescent with T1DM must embrace an outlook on interdependence in which all family members take responsibility for disease management.

It has been noted that individuals with T1DM are more concerned with their weight than are disease-free subjects, potentially predisposing this subset to the development of eating disorders.¹³ One study found that eating disorders occurred in twice as many teenage girls with T1DM (diagnosis in 10%) versus disease-free controls (diagnosis in 4%).¹⁴ Interestingly, subthreshold eating disorders—characterized by milder, less frequent symptoms and not meeting DSM-IV criteria for diagnosis of a clinically apparent eating disorder—were more prevalent, occurring in 14% of T1DM patients and 8% of controls.¹⁴ Disturbed eating patterns may present prior to adolescence, occurring as early as age 9 years; one study of preteen girls demonstrated an incidence rate of subthreshold eating disorders of approximately 8% in T1DM patients versus 1% of controls.¹⁵ While most distorted dietary behaviors in diabetes patients are classified as bulimia, anorexia occurs as well, although to a much lesser extent (TABLE 1).⁴ Eating disturbances that present early in the diagnosis of diabetes tend to persist, leading to poor glycemic control and potential complications into adulthood—specifically microvascular complications, especially retinopathy.¹⁶

Characteristics and Sequelae of Eating Disorders in T1DM

A multitude of factors are involved in the development of clinically relevant eating disorders, including biological, genetic, psychological, and sociocultural variables.¹ These factors may be more pronounced in young females with T1DM, resulting in a lower threshold at which disturbed eating patterns evolve. Eating disorders are commonly characterized by body dissatisfaction, dietary restraint, a preoccupation with food, an obsession with thinness, and a desire for control, and certain aspects of a comprehensive diabetes-management program can complicate these factors.¹⁷

The clinical sequelae of eating disorders can be severe and may lead to substance abuse, personality disorders, and medical complications such as electrolyte abnormalities, cardiac conduction changes, and mood disorders, all of which may be magnified in the diabetes patient.¹⁸ Insulin, the only viable treatment for T1DM, is associated with adverse effects such as hypoglycemia and weight gain.¹⁹ The most frequently cited reason for insulin omission in young women is weight control, occurring in 10% to 15% of adolescent patients and becoming much more prevalent in older adults (almost 40%).^14,16,20

Insulin omission has been cited as the most common characteristic of purging behavior in patients with T1DM.²¹ Although purging insulin is typically identified in cases of bulimia, it may occur in cases of anorexia as well, typically as a means of preventing the onset of hypoglycemia.²² Although the term is not recognized by DSM-IV, insulin omission in T1DM patients is referred to as diabulimia.^8,18 Through intentional insulin omission, the patient induces a hyperglycemic state resulting in polyuria and caloric reduction, a unique and individualized method for inducing weight loss.⁸ Unfortunately, eating disorders in T1DM patients are associated with poor metabolic control as well as an earlier onset of metabolic complications.¹⁷ Inadequate treatment of hyperglycemia with insulin has been associated with dehydration, ketoacidosis, and fatigue in the short term.¹³ In one study examining long-term consequences, young women with diabulimia who self-reported insulin restriction had a threefold risk of death and higher rates of nephropathy and foot problems compared with subjects who administered insulin appropriately.²³

Eating Disorders and Self-Care

Another potential eating disturbance in T1DM patients is binge-eating disorder (BED). Occurring in as many as 80% of young women with T1DM, BED is described by DSM-IV as the recurrent consumption of objectively large quantities of food in a defined time period and is characterized by a feeling of loss of control during the eating episode.² In patients with T1DM, BED may be triggered by the fear of developing hyperglycemia or by its actual presence.²⁴

While dietary restraint and physical activity are components of the comprehensive treatment of T1DM, clinicians must recognize that these behaviors also occur in eating disorders. Unfortunately, the extreme vigilance that diabetes patients must maintain regarding dietary habits and exercise as a part of disease management may predispose some individuals to abnormal eating patterns.²³ Altered dietary patterns through bingeing, dietary avoidance, and overall inadequate disease management often result in prolonged hyperglycemia in the diabetes patient, potentially causing microvascular complications and even fatality.¹³ In one study, after 10 years of follow-up, subjects with T1DM and anorexia had a mortality rate of 34.6 per 1,000 person-years compared with 7.3 for disease-free controls.²⁵ At diagnosis and during follow-up, patients should be counseled regarding proper nutrition, balanced meals, and the prevention of hypoglycemia to avoid potential eating-disorder triggers.

The presence of eating disorders in the T1DM patient can negatively affect daily diabetes management.¹⁸ It has been theorized that self-care and glycemic control can deteriorate in individuals with eating disorders.⁴ In the case of diabetes, some patients with eating disorders may resist glucose self-monitoring to avoid dealing with the reality of their disease state and the potential risk of complications. Clinicians should work with T1DM patients to identify abnormal behaviors and the underlying reasoning behind the patient’s actions.²⁴

Approach to Treatment

Routine screening for the presence of eating disorders in T1DM patients is essential for the prevention of disordered eating and disease-related complications, as the potential medical consequences of eating disorders in T1DM patients are magnified compared with those in patients without T1DM.¹⁶ There are no screening tools specifically designed to identify disordered dietary patterns in patients with T1DM, so tools used for screening the general population are often administered. Practitioners must realize that these tools may have limited application for the T1DM patient—they are often nonspecific and may not capture disordered patterns suggestive of eating disorders in this population, such as insulin omission.¹³

Additionally, clinicians must recognize that signs and symptoms of disordered eating may be less obvious in T1DM patients than in nondiabetic individuals undergoing treatment for eating disorders.¹⁶ A common finding in the diagnosis of eating disorders is abnormally low BMI and weight; however, in T1DM patients, intensive insulin therapy may result in higher BMI and normal weight.²⁶ Unfortunately, these subclinical symptoms may lead to late identification of disordered eating, possibly after microvascular complications have already set in. TABLE 2 identifies signs and symptoms suggestive of eating disorders in T1DM patients.

Interventions for early identification of eating disorders in T1DM patients must be a component of a routine and comprehensive diabetes treatment plan and should encompass questions about body image, weight, shape, dieting, and behavior. Patients who present with abnormal dietary patterns should be encouraged to maintain blood glucose logs, food diaries, and records of insulin administration and any insulin manipulations; this information will provide the health care practitioner with a more detailed clinical picture. A practitioner who suspects the presence of an eating disorder in a T1DM patient should refer the patient to a dietitian or certified diabetes educator experienced in this area. All clinicians, however, must be aware that encouraging strict attention to and vigilance regarding diet can trigger abnormal dietary behaviors.²⁴

Specialized Treatment

It has been demonstrated that patients with T1DM and eating disorders benefit from specialized treatment focusing on both the abnormal behavior and diabetes management.²⁷ While treatment would encompass the traditional focuses of all eating-disorder treatment plans (i.e., improving body satisfaction and image, identifying troubling behavior, and enhancing self-care), T1DM patients would receive a more specialized approach. Particular attention would be paid to diabetes-specific behaviors including insulin-administration practices, specific dietary habits, and psychosocial issues inherent in living with a chronic medical condition.²⁴

The Family’s Role

Familial involvement is associated with better clinical outcomes in the management of T1DM in the adolescent patient.²⁸ All family members must accommodate and adjust to having a family member with a chronic disease. The challenge, however, lies in the growing wish for autonomy and independence that occurs during adolescence. In young T1DM patients, full autonomy is often impractical, as parental involvement is essential for successful disease management. Research suggests that T1DM patients with eating disorders often have families who do not acknowledge the importance of independence and autonomy.⁶ As a result, the patient manifests a desire for control, in this case by altering disease management and weight.⁶ Clinical interventions centered on family-based therapies, with an emphasis on problem solving, coping strategies, and advocating a healthy balance between parents and patient, are essential in the management of T1DM.

Conclusion

Without question, the diagnosis of T1DM triggers a major transition for the entire family. Because of the pressures and stresses of living with a chronic medical condition, adolescents with T1DM are at higher risk for developing psychiatric disorders. By focusing on proper prevention and treatment, advocating a partnership between patient and family for disease management, identifying potentially troubling behaviors, and providing adequate emotional support, the provider can help ensure that the psychosocial, medical, and emotional needs of the young patient with T1DM are met.

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