**7. Metabolic consequences and vascular complications of disordered eating behaviors and eating disorders in type 1 diabetics**

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

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 disease and even death.

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

Inadequate Coping Attitudes, Disordered Eating

learned and maintained.

**8.1 Social problem solving** 

(Duangdao & Roesch, 2008).

**8.2 Conflict resolution** 

communication skills.

**8.3 Communication skills training** 

Berry, 2004).

Behaviours and Eating Disorders in Type 1 Diabetic Patients 103

Several major trial carried out in the past decades, have demonstrated that intensive diabetes management for type 1, as well as type 2 diabetes, can delay or prevent the onset and progression of many complications of the disease, especially microvascular complications (DCCT, 1993; UKPDS, 1998). Such studies also have demonstrated that achieving excellent glycaemia control requires complex self-management behaviors to be

Traditionally, diabetes education has focused on increasing knowledge about diabetes and its care and increasing skills to perform self-care behaviors, such as blood glucose monitoring. However, it is clear that although knowledge and skills are important prerequisites to diabetes self-management, additional training in the application of this knowledge and skills in day-to-day living are necessary for longer-term maintenance and improved outcomes. Cognitive-behavioral interventions such as coping skills training focus primarily on improving behavioral skills are necessary to achieve better glycaemia and psychosocial outcomes in patients with diabetes and in their relative members (Grey &

Social problem solving assists individuals when they are faced with peer or family pressures or any decision in which they are confronted with a dilemma. Social problem solving is a process by which an individual learns to think through the steps of having a problem and reaching a decision about how to handle the problem. The process assists individuals to look at all possible outcomes of situations and the possible consequences of their decisions

The basis of conflict resolution is the acquisition of skills necessary to resolve conflict in a positive manner that results in positive outcomes for all parties involved in the conflict (Deustsch & Brickman, 1994). The first step in this training is development of the understanding that in any conflict both parties can win and that every conflict should be approached in this manner. The individual is helped to focus on clear communication and problem-solving skills. Once the conflict is identified, all possible outcomes and the consequences to these outcomes are explored. Role-playing can then be set up to try out the communication of the decision. Role-play is used as both forms of practice and feedback on

This kind of training aims to help individuals express themselves in ways that are clear, appropriate, and constructive. Two main skills are identified under communication skills training: social skills training and assertiveness training. Models for social skills training include those by Carteledge & Milburn (Carteledge & Milburn, 1980) and Goldstein *et al.*  (Goldstein et al, 1980). These models strive to teach individuals how to work with others in a way that will result in positive outcomes for all. Assertiveness training permits one to communicate in ways that are direct, honest, and appropriate. Working groups allow

**8. Management of inadequate coping attitudes in type 1 diabetic patients** 

with DEB had an increased risk for retinopathy (Rydall et al, 1997). A more recent longitudinal study observed that diabetic patients aged 11 to 25 years with DEB or insulin misuse had a significant risk for the development of two or more serious complications, such as repeated episodes of diabetic ketoacidosis, increased rate of hospital admission and mortality (Peveler et al, 2005).

Therefore, ED in type 1 diabetics have clearly shown to be associated with impaired metabolic control (Jones et al, 2000; Vila et al, 1993; Friedman S et al, 1995; Affenito et al 1997; Affenito et al 1998; Rydall et al, 1997), more frequent episodes of ketoacidosis (Polonsky et al, 1994), and an earlier than expected onset of diabetes-related microvascular complications, particularly, retinopathy (Affenito et al, 1997; Colas et al, 1991; Rydall et al, 1997; Steel et al, 1987; Ward et al, 1995). In this sense, disordered eating status was more predictive of diabetic retinopathy than was the duration of diabetes, which is a wellestablished risk factor for microvascular complications (Diabetes Control and Complications Trial Research Group, 1993). Furthermore, ED in type 1 diabetic patients is associated with high mortality (Walker et al, 2002).

Regarding to mortality, an 11-year follow-up study reports that insulin restriction conveyed more than a three-fold increased risk of mortality in type 1 diabetic patients after controlling for age, body mass index and HbA1c values. Age of death was younger among insulin restrictors, with a mean age of death of 45 years, as compared to 58 years among those reporting appropriate insulin use (Goebel-Fabbri et al, 2007).

Insulin restriction becomes a more significant problem in older adolescents and in early adulthood. Once the pattern of frequent and habitual insulin restriction becomes entrenched, its consequent poor diabetes self-care can be complex and difficult to treat. Figure 1.

Fig. 1. Consequences of insulin misuse in type1 diabetic patients.
