**5. Clinical forms of eating disorders in type 1 diabetics**

The three diagnostic forms of ED are AN, BN and EDNOS. Common to all three is a core problem in which the self-evaluation is unduly influenced by body weight or shape. This can be characterized by an extreme pursuit of thinness, in the case of AN, or recurrent episodes of binge eating and compensatory caloric purging behaviors, in the case of BN. EDNOS encompasses those ED that are clinically significant enough to compromise the patient health and the quality of life, but do not meet formal diagnostic criteria for AN or BN (American Psychiatric Association, 1994).

Eating disorders that meet Diagnostic and Statistical Manual of Mental Disorders four edition (DSM-IV) diagnostic criteria, mostly bulimia nervosa and EDNOS, are more than twice as common in girls with diabetes compared to their non-diabetic peers, furthermore, subthreshold eating disorders were also almost twice as common in girls with diabetes compared to controls (American Psychiatric Association, 1994). In line with these studies, it was found that the ED associated with bingeing and purging are the most common types of ED among girls with diabetes as they are in girls in the general population (American Psychiatric Association, 1994; Fairburn & Beglin, 1990; Jones et al, 2001). Restricting ED are much less common conditions (Jones et al, 2000), thus a specific association between anorexia nervosa and type 1 diabetes has not been demonstrated (Rodin et al, 2002).

In a longitudinal study by Colton et al, (Colton et al, 2007), at 5 years, 49% of a cohort of girls with type 1 diabetes reported current disordered eating behavior (DEB), 43.9% active dietary restraint, 6.1% binge-eating episodes, 3.1% self-induced vomiting, 3.1% insulin omission and 25.5% excessive exercise for weight control. Furthermore, 13.3% met criteria for an ED: three girls had bulimia nervosa, three had an eating disorder not otherwise specified and seven had a subthreshold ED.

Using the DSM-III-R or the DSM-IV for interview-based diagnosis, the prevalence of AN varies between 0.0-1.8% for diabetic patients, whereas 0.0-0.6% for controls. The prevalence of BN was 0.0-5.8% and 0.0-2.0%, respectively (Engström et al, 1999; Fairburn et al, 1991; Jones et al, 2000; Mannucci et al, 1995; Peveler et al, 1992; Robertson et al, 1990; Striegel-Moore et al, 1992; Vila et al 1995). In a study that aimed to determine the prevalence of ED in young adolescents, 98 type 1 diabetic patients and 575 age-matched controls were studied. The authors found neither AN nor BN case among diabetics and controls. However, the prevalence of EDNOS was significantly higher in adolescent diabetics than in controls both in boys (1.7% vs. 0.9% respectively) and girls (5.3% vs. 1.6% respectively). In addition, subthreshold ED were more common in male diabetic adolescents than in non-diabetic peers (García-Reyna et al, 2004). In a meta-analysis by Mannucci et al (Mannucci et al, 2005),

Inadequate Coping Attitudes, Disordered Eating

Behaviours and Eating Disorders in Type 1 Diabetic Patients 101

Insulin restriction becomes a more significant problem in older adolescents, perhaps as parental supervision of insulin administration decreases. It becomes more common a potential worsening in severity and frequency throughout early adulthood. Once the pattern of frequent and habitual insulin restriction became entrenched, the cycle of negative feelings about body image, shape and weight; chronically elevated blood sugars; depression, anxiety

In a study that looked at 143 adolescents with type 1 diabetes who completed the Assessing Health and Eating among Adolescents with Diabetes survey; unhealthy weight control practice was observed in 37.9 % of females and 15.9% of males. Among the females, 10.3% reported skipping insulin and 7.4 % reported taking less insulin to control their weight (Neumark-Sztainer et al, 2002). Only one male reported doing either of these behaviors. In another 4 years follow-up study of 91 girls with diabetes aged 12 to 18, dieting was reported by 38% of the sample, binge eating by 45%, insulin omission by 14 % and self-induced vomiting by 8% at baseline, these behaviors were even more common at follow-up, when most of the girls were in the age of the highest risk for ED. At this time, more than half of the sample reported dieting for weight loss and binge eating, and one-third reported deliberate

In general terms, it is estimated that between 30% and 40% of adolescents and young adults

**7. Metabolic consequences and vascular complications of disordered eating** 

There is a spectrum of severity of disturbance of eating habits and attitudes, and subthreshold eating problems, seen as relatively mild in non diabetic patients, can give rise to clinically important disturbances of self-care and glycaemia control in diabetics. In general terms, glycosilated hemoglobin was higher in patients with diabetes who had ED compared with those with diabetes without ED (Affenito & Adams, 2001). A study by Rydall et al (Rydall et al, 1997), found that the mean HbA1c was significantly higher among girls with clinical DEB compared to those moderately disordered of eating habits or with no disordered behavior. Another 3-year longitudinal study by Figueroa Sobrero et al (Figueroa Sobrero et al, 2010) revealed that the presence and persistence of disordered eating behavior

The lack of proper insulin treatment in type 1 diabetics may lead to many harmful physical effects. Reducing insulin to lose weight increases the risk of dehydration, break down of muscle tissue, high risk of developed infections and fatigue. If this behavior continues, it may also result in kidney failure, eye disease leading to blindness, vascular

In particular, patients who misuse insulin to control body weight (Crow et al, 1998; Rodin et al, 1989), are thought to be at increased risk for microvascular complications (Rydall et al, 1997; Steel et al, 1987), but the extent of the risk has not been well characterized, as most studies have been cross-sectional. Clinical outcome in terms of physical and psychological health are not known with certainty. One longitudinal study of patients with diabetes and DEB over 9 years, found a low rate of microvascular complications (Pollock et al, 1995). On the contrary, another study, taking place over 4 years, found that insulin-dependent girls

with diabetes skip or reduce insulin after meals to lose weight (Hasken 2010).

is associated with worse prognosis in type 1 diabetic children and adolescents.

and shame; and poor diabetes self-care can be complex and difficult to treat.

insulin omission to prevent weight gain (Rydall et al, 1997).

**behaviors and eating disorders in type 1 diabetics** 

disease and even death.

they found that the prevalence of AN in type 1 diabetes was not significantly different from that in controls, being 0.27 vs. 0.06 %, respectively, while the prevalence of BN was 1.23 vs. 0.69 %, respectively, p < 0.05, in line with previous studies (Affenito et al, 1997; Jones et al, 2000; Vila et al, 1995).

The cited data indicate that young type 1 diabetic patients have a higher prevalence of BN, EDNOS and subthreshold ED than their non-diabetic peers. Data are summarized in Table 1.


Table 1. Estimated prevalence of ED and DEB in type 1 diabetic patients.
