**Inadequate Coping Attitudes, Disordered Eating Behaviours and Eating Disorders in Type 1 Diabetic Patients**

Ricardo V. García-Mayor and Alejandra Larrañaga *Eating Disorders Section, Endocrinology, Diabetes, Nutrition and Metabolism Department, University Hospital of Vigo Spain* 

#### **1. Introduction**

94 Type 1 Diabetes – Complications, Pathogenesis, and Alternative Treatments

Nabors, L., Lehmkuhl, H., Christos, N., & Andreone, T. L. (2003). Children with diabetes:

Peters, C. D., Storch, E. A., Geffken, G. R., Heidgerken, A. D., & Silverstein, J. H. (2008).

Rabiau, M. A., Knuper, B., Nguyen, T-K, Sufrategui, M., & Polychronakos, C. (2009).

Rolland, J. S. (1987). Chronic illness and the life cycle: A conceptual framework. *Family* 

Rosenstock, I. M. (1974). Historical origins of the Health Belief Model. *Health Education* 

Rotter, J. B. (1966). Generalized expectancies of internal versus external control of reinforcements. *Psychological Monographs*, Vol.80 (whole no. 609), ISSN 0096-9753 Shroff-Pendley, J., Kasmen, L. J., Miller, D. L., Donze, J., Swenson, C., & Reeves, G. (2002).

Seiffge-Krenke, I., & Stemmler, M. (2003). Coping with everyday stress and links to medical

Silverstein, J., Klingensmith, G., Copeland, K., Plotnick, L., Kaufman, F., Laffel, L., et

Skinner, T. C., John, M., & Hampson, S. E. (2000). Social support and personal needs models

Skinner, T. C., & Hampson, S. E. (1998). Social support and personal models of diabetes in

Storch, E.A., Heidgerken, A.D., Geffken, G.R., Lewin, A.B., Ohleyer, V., et al. (2006).

Weissberg-Benchell, J., Goodman, S. S., Lomaglio, J. A., & Zebracki, K. (2007). The use of

Wysocki, T., Greco, P., Harris, M. A., Bubb, J., & White, N. H. (2001). Behavior therapy for

*of Pediatric Psychology,* Vol.32, No.10, pp. 1196-1202, ISSN 0146-8693

Diabetes, *Journal of Pediatrics*, Vol.148, No.6, pp. 784-787, ISSN 0022-3476 Streisand, R., Mackey, E. R., Elliot, B. M., Mednik, L., Slaughter, I. M., Turek, J. et al. (2008).

*Education Research*, Vol.24, pp. 890-896, ISSN 0012-3692

*Pediatric Psychology*, Vol.27, No.5, pp. 429-438, ISSN 0146-8693

*Journal of Adolescence*, Vol.21, pp. 703-715, ISSN 0140-1971

*and Counseling,* Vol.73, pp. 333-338, ISSN 0738-3991

*Care*, Vol.24, pp. 441-446, ISSN 0149-5992

*Process*, Vol.26, pp. 203-221, ISSN 0014-7370

Vol.33, pp. 180-188, ISSN 1054-139X

186-212, ISSN 0149-5992

0146-8693

*Monographs*, Vol.2, pp. 328-335, ISSN 0073-1455

Vol.73, pp. 216-221, ISSN 1746-1561

1367-4935

Perceptions of supports for self-management at school. *Journal of School Health*,

Victimization of youth with type-1 diabetes by teachers: Relations with adherence and metabolic control. *Journal of Child Health Care*, Vol.12, No.3, pp. 209-220, ISSN

Compensatory beliefs about glucose testing are associated with low adherence to treatment and poor metabolic control in adolescents with Type I diabetes. *Health* 

Peer and family support in children and adolescents with type I diabetes. *Journal of* 

and psychosocial adaptation in diabetic adolescents. *Journal of Adolescent Health*,

al.(2005). Children and adolescents with Type 1 diabetes. *Diabetes Care*, Vol.28, pp.

of diabetes as predictors of self-care and well-being: A longitudinal study of adolescents with diabetes. *Journal of Pediatric Psychology,* Vol.25, pp. 257-267. ISSN

relation to self-care and well-being in adolescents with type 1 diabetes mellitus.

Bullying, regimen self-management, and metabolic control in youth with Type I

Parental anxiety and depression associated with caring for a child newly diagnosed with type 1 diabetes: Opportunities for education and counseling. *Patient Education* 

continuous subcutaneous insulin infusion (CSII): Parental and professional perceptions of self-case mastery and autonomy in children and adolescents. *Journal* 

families of adolescents with diabetes: Maintenance of treatment effects. *Diabetes* 

Diabetes mellitus has been found to be the sixth leading cause of death for those living in the United States affecting the young and old at an alarming rate (National Center for Health Statistics, 2011). Type 1 diabetes typically has an early onset in life, but can occur at any age. It primarily develops when the body's own immune system attacks and destroys pancreatic beta cells, which produce the hormone insulin that regulates blood glucose levels. This type of diabetes accounts for 5 to 10 % of all diagnosed cases. Type 2 diabetes affects mainly adult subjects, its prevalence around the world has increased in relationship with the increase of the prevalence of overweight and obesity, attributed to lifestyle changes such as sedentary habits and overeating. Consequently, diabetes is one of the most challenging and burdensome chronic diseases of the 21st century, and it is a growing threat to the world's public health (King et al, 1995; King et al, 1998). Diabetes mellitus, especially type 1 form represent a very hard experience that requires subsequent psychological adaptation. Unfortunately, this often does not occur and it is followed by frustration and the nonacceptance of the disease. Problems with coping are one of the important consequences of the disease and the cause of uncountable problems in the future.

The management of type1 diabetes and its associated health-risk factors are often complex and require considerable patient education and frequent medical monitoring (Koopmanschap, 2002). The participation of the patients is basic in order to obtain a correct degree of metabolic control; however, this carries as a consequence considerable amount of stress. People on insulin must learn how to regulate their blood sugars by monitoring blood glucose levels daily while carefully attending to their food intake and an exercise regimen. Careful blood glucose monitoring is necessary to prevent wide variations in blood sugars that affect both short term and long term health and functioning. Hypoglycaemia reactions are a concern in the short run not only because they are frightening and disruptive, but also because, when severe, they can lead to unconsciousness, coma and death (Cox & Gonder-Frederick, 1992). The constant stress of maintaining tight glycaemia control can result in two types of psychological distress (a) subclinical emotional distress, and (b) diagnosable psychological disorders (Rubin & Payrot, 2001). Additionally, psychiatric conditions can

Inadequate Coping Attitudes, Disordered Eating

(Bombardier et al, 1990).

of confidence.

Behaviours and Eating Disorders in Type 1 Diabetic Patients 97

chronic illness yields the following outcomes: successful performance of adaptive tests, absence of psychological disorders, low experience of negative affect, improved functional

Coping can generally be defined as cognitive and/or behavioral attempts to manage and tolerate situations that are appraised as stressful to an individual. No single coping strategy or dimension can be considered maladaptive. The quality of the coping strategy and process is evaluated according to its impact on the outcome of interest. From the previous conceptual definition, Folkman and Lazarus (Folkman & Lazaruz, 1980; Folkman & Lazaruz, 1985; Folkman & Lazaruz, 1988) distinguished two primary dimensions of coping (or categories): emotion-focused (composed of individual coping strategies such as seeking emotional support) and problem-focused (composed of individual coping strategies such as making a plan of action). These coping categories described efforts to either alleviate the personal emotional stress induced by the stressor or alter the source of stress in the environment. Use of problem-focused coping has been found to be associated with better metabolic control, emotional status, and better adjustment overall in patients with diabetes (Lundman & Norberg, 1993); use of emotion-focused coping has been found to be associated with poor adjustment and adherence to health regimens in chronically ill samples

Diabetic patients initially experience high levels of depression and anxiety (Lustman et al, 1997; Tuncay, 2008). Anderson et al. (Anderson et al, 2001) found that adults with diabetes have twice the odds of comorbid depression. It was also found that this prevalence was much higher in women than in men. Within their sample, one in every three individuals had a level of depression that impaired their ability to function on a daily basis which in turn affected quality of life, regimen adherence, and blood glucose control. Regarding to coping strategies, it has been shown that problem-focused coping was positively associated with glycaemia control and negatively associated with anxiety and depression (Maes et al, 1996). Smari and Valtysdottir (Smari & Valtysdottir, 1997) also found that problem-focused coping was associated with lower blood glucose levels—indicative of better adjustment. On the contrary, individuals who engaged in more emotion-focused types of coping experienced more anxiety, depression, and higher levels of glycaemia. It is obvious that any deviation from a normal routine or health status serves as a continual source of stress that leads to the individuals' inability to care for themselves (White et al, 1992). Therefore, management of

this stress via coping strategies is crucial for psychological and physical health.

An author found that treating depression through therapy is effective for individuals with diabetes so they may regain confidence and abilities to control the disease, leading to improved quality of life and social and physiological functioning (Eisenberg, 1992). The treatment includes the development of coping skills through training programs (Grey & Berry, 2004) as well as patient empowerment (Anderson et al, 1995). DeRidder and Schreurs (DeRidder & Schreurs, 2001) observed that diabetic patients in particular are inclined to use coping strategies that are aimed at reducing the negative emotions surrounding the disease and its maintenance. If this suggestion was found to be empirically true across diabetes studies and patients, it may portend a particularly problematic issue since these strategies were generally viewed as less adaptive. It is apparent that stress permeates the management of diabetes and thus use of effective coping skills is imperative not only in illness management but general stress management as well. At present, there is no systematic quantitative review of the stress and coping literature in diabetes that links coping strategies to indices of adjustment. Thus, a summary statement of the adaptive versus maladaptive strategies identified for these coping-adjustment relations cannot be made with any degree

status, and appraisals of well-being in varying life domains (Stanton et al, 2001).

occur independently without being a consequence of diabetes. It has been shown that individuals with diabetes have a disproportionately higher rate of psychiatric disorders (Bogner et al, 2007; Llorente & Urrutia, 2006), with affective and anxiety disorders being more commonly diagnosed than in the general population (De Mont-Marin et al, 1995). This is evidenced by research showing high rates of psychiatric disorders, particularly depression and anxiety, for example, Fettahoglu et al., (Fettahoglu et al, 2007) found over 40% increased risk in having any type of psychiatric disorder in patients with diabetes, and Gülseren et al. (Gülseren et al, 2001) found that depression and anxiety account for 45% of psychiatric disorders in patients with diabetes. These results show the negative impact that diabetes can have on an individual's psychosocial adjustment, and the need for research to determine the most appropriate and common coping strategies to deal with the stress of illness.

Other psychological problems of these patients are Eating Disorders (ED). The classical ED are anorexia nervosa (AN) and bulimia nervosa (BN), but recently another entity was recognized, the so called eating disorders not otherwise specified (EDNOS), which are incomplete forms of classical ED that are diagnosed when patients did not fulfill the classical ED diagnostic criteria. Type 1 diabetic patients have a high risk of suffering from ED due to these patients have to select the food they eat carefully in an early period of their development and because both entities, type 1 diabetes and ED, often affect adolescents and young adults. Furthermore, type 1 diabetic patients suffer from other eating behavior anomalies, which mainly appear in girls, that consist in spliting insulin doses or restricting food intake in order to reduce their body weight, but with the high price of the metabolic disturbance and subsequent chronic vascular complications if such behavior persists over time.

In this chapter we will review these psychological anomalies suffered by type 1 diabetic patients, especially problems with coping attitudes, disordered eating behaviors (DEB) and eating disorders (ED), and also discuss some aspects of their forms of presentation, management and prevention.
