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
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,
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
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
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
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.
1. Treasure J, Claudino AM, Zucker N. Eating disorders. Lancet. 2010;375:585-593.
2. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Washington, DC: American Psychiatric Association; 1994.
3. Eating Disorders Coalition. Facts about eating disorders: what the
Accessed February 10, 2012.
4. Kakleas K, Kandyla B, Karayianni C, Karavanaki K. Psychosocial problems in adolescents with type 1 diabetes. Diabetes Metab. 2009;35:339-350.
5. Christie D, Viner R. Adolescent development. BMJ. 2005;330:303-304.
6. Maharaj S. Contribution of the family environment to eating disturbances in girls with type 1 diabetes. Diabetes Spectrum. 2002;15:95-98.
7. Pound N, Sturrock ND, Jeffcoate WJ. Age-related changes in
glycated haemoglobin in patients with insulin-dependent diabetes
mellitus. Diabet Med. 1996;13:510-513.
8. Ruth-Sahd LA, Schneider M, Haagen B. Diabulimia: what it is and how to recognize it in critical care. Dimens Crit Care Nurs. 2009;28:147-153.
9. Frank MR. Psychological issues in the care of children and adolescents with type 1 diabetes. Paediatr Child Health. 2005;10:18-20.
10. Mulvaney SA, Mudasiru E, Schlundt DG, et al. Self-management in type 2 diabetes: the adolescent perspective. Diabetes Educ. 2008;34:674-682.
11. Davis CL, Delamater AM, Shaw KH, et al. Parenting styles, regimen
adherence, and glycemic control in 4- to 10-year-old children with
diabetes. J Pediatr Psychol. 2001;26:123-129.
12. Delamater A. Working with children who have type 1 diabetes. In: Anderson BJ, Rubin RR, eds. Practical Psychology for Diabetes Clinicians. 2nd ed. Alexandria, VA: American Diabetes Association; 2002:127-137.
13. Hasken J, Kresl L, Nydegger T, Temme M. Diabulimia and the role of school health personnel. J Sch Health. 2010;80:465-469.
14. Jones JM, Lawson ML, Daneman D, et al. Eating disorders in
adolescent females with and without type 1 diabetes: cross sectional
study. BMJ. 2000;320:1563-1566.
15. Colton P, Olmsted M, Daneman D, et al. Disturbed eating behavior
and eating disorders in preteen and early teenage girls with type 1
diabetes: a case-controlled study. Diabetes Care. 2004;27:1654-1659.
16. Rydall AC, Rodin GM, Olmsted MP, et al. Disordered eating
behavior and microvascular complications in young women with insulin
dependent diabetes mellitus. N Engl J Med. 1997;336:1849-1854.
17. Daneman D, Rodin G, Jones J, et al. Eating disorders in adolescent girls and young adult women with type 1 diabetes. Diabetes Spectrum. 2002;15:83-105.
18. Colton P, Rodin G, Bergenstal R, Parkin C. Eating disorders and diabetes: introduction and overview. Diabetes Spectrum. 2009;22:138-142.
19. Nathan DM, Buse JB, Davidson MB, et al. Medical management of
hyperglycemia in type 2 diabetes: a consensus algorithm for the
initiation and adjustment of therapy: a consensus statement of the
American Diabetes Association and the European Association for the Study
of Diabetes. Diabetes Care. 2009;32:193-203.
20. Biggs MM, Basco MR, Patterson G, Raskin P. Insulin withholding for weight control in women with diabetes. Diabetes Care. 1994;17:1186-1189.
21. Howe CJ, Jawad AF, Kelli SD, Lipman TH. Weight-related concerns
and behaviors in children and adolescents with type 1 diabetes. J Am Psychiatr Nurses Assoc. 2008;13;376-385.
22. Takii M, Uchigata Y, Nozaki T, et al. Classification of type 1
diabetic females with bulimia nervosa into subgroups according to
purging behavior. Diabetes Care. 2002;25:1571-1575.
23. Goebel-Fabbri AE, Fikkan J, Franko DL, et al. Insulin restriction
and associated morbidity and mortality in women with type 1 diabetes. Diabetes Care. 2008;31:415-419.
24. Olmsted M. Treating eating disorders in young women with diabetes. Diabetes Spectrum. 2002;15:99-102.
25. Nielsen S. Eating disorders in females with type 1 diabetes: an update of a meta-analysis. Eur Eat Disord Rev. 2002;10:241-254.
26. DCCT Research Group. Influence of intensive diabetes treatment on
body weight and composition of adults with type 1 diabetes in the
Diabetes Control and Complications Trial. Diabetes Care. 2001;24:1711-1721.
27. Peveler RC, Fairburn CG. The treatment of bulimia nervosa in patients with diabetes mellitus. Int J Eating Disord. 1992;11:45-53.
28. Anderson B, Ho J, Brackett J, et al. Parental involvement in
diabetes management tasks: relationships to blood glucose monitoring
adherence and metabolic control in young adolescents with
insulin-dependent diabetes mellitus. J Pediatr. 1997;130:257-265.
29. Criego A, Crow S, Goebbel-Fabbri AE, et al. Eating disorders and diabetes: screening and detection. Diabetes Spectrum. 2009;22:143-146.
To comment on this article, contact email@example.com.