**4. Epidemiology of disordered eating behavior and eating disorders in type 1 diabetic patients**

Disordered eating behavior (DEB) is common in young women living in westernized countries, where thinness is valued and dietary restraint is pursued (Attie & Brook-Gunn, 1989). Prevalence studies in North America indicate that full syndrome bulimia nervosa may be found in 1-3% of adolescents and young adult women and subthreshold disorders are even more common (American Psychiatric Association, 1994; Fairburn & Beglin, 1990; Jones et al, 2001). The rates of these disorders are lower but rising in less-westernized countries such as Asia and Africa as Western attitudes towards weight and shape become more pervasive (Hoek, 1993; Lee, 1993; Lee & Lee 1996). Differences in the prevalence of eating disorders varies according to different ethnic groups (Abrams et al, 1993; Kumanyika, 1993), however, a study found that ethnic differences in eating disorder symptoms disappeared when body mass index (BMI) was controlled (Arriaza & Mann, 2001). At present, there is no information on the effect of culture and race on eating disorders in people with diabetes.

The risk of eating disturbances has been postulated to be higher in type 1 diabetic patients than in the general population due to multiple interacting factors related to diabetes and its treatment (Colton et al, 1999; Rodin & Daneman, 1992). Diabetes management imposes some degree of perceived dietary restraint, particularly patients who eat according to a predetermined meal plan, rather than in response to internal cues for hunger and satiety. Such neglect of internal cues may contribute to dietary dysregulation in susceptible individuals (Polivy & Herman, 1985). The relationship between higher weight and DEB presents a management dilemma for clinicians, since both dietary restraint and higher weight are clear risk factors for the development of ED and their negative health consequences.

Although until recently it has been unclear whether there is a specific association of eating disorders with diabetes, some studies have suggested an increased incidence of eating disorders in young women with diabetes (Birk & Spencer, 1987; Engstrom et al, 1999; Hudson et al, Lloyd et al, 1987; 1985; Rodin et al, 1985; Rodin et al, 1986/1987; Rodin et al, 1991; Rosmark et al, 1986; Stancin et al, 1989; Steel et al, 1987; Vila, et al, 1993; Vila et al, 1995) whereas others did not find such an increase (Bryden et al, 1999; Fairburn et al, 1991; Friedman et al, 1995; Mannucci et al, 1995; Marcus et al, 1992; Meltzer et al, 2001; Peveler et al, 1992; Powers et al, 1990; Robertson & Rosenvinge, 1990; Striegel-Moore et al, 1992; Wing et al, 1986). However, the conclusions of these studies are limited by the small sample sizes of females in the age of the highest risk for eating disturbances, the absence of control groups, their low statistical power, and/or by the lack of structured diagnostic interviews for the assessment of eating disorders.

A study examined the association between ED and type 1 diabetic girls, aged 12-19, for at least 1 year. Subjects with diabetes were 2.4 times more likely than non diabetic controls to have a clinical ED and 1.9 times more likely to have a subthreshold ED (Affenito & Adams, 2001). In another investigation, the prevalence of ED in a population-based cohort of female adolescents with type 1 diabetes was compared with that found in aged-matched controls. DEB was found in 16.9% of adolescents with diabetes compared with 2.2% of the controls (Hoek, 1993). A longitudinal study of 87 patients with diabetes aged at baseline 11-25 years, in whom eating habits and attitudes were assessed by a semistructured research diagnostic

**4. Epidemiology of disordered eating behavior and eating disorders in type 1** 

Disordered eating behavior (DEB) is common in young women living in westernized countries, where thinness is valued and dietary restraint is pursued (Attie & Brook-Gunn, 1989). Prevalence studies in North America indicate that full syndrome bulimia nervosa may be found in 1-3% of adolescents and young adult women and subthreshold disorders are even more common (American Psychiatric Association, 1994; Fairburn & Beglin, 1990; Jones et al, 2001). The rates of these disorders are lower but rising in less-westernized countries such as Asia and Africa as Western attitudes towards weight and shape become more pervasive (Hoek, 1993; Lee, 1993; Lee & Lee 1996). Differences in the prevalence of eating disorders varies according to different ethnic groups (Abrams et al, 1993; Kumanyika, 1993), however, a study found that ethnic differences in eating disorder symptoms disappeared when body mass index (BMI) was controlled (Arriaza & Mann, 2001). At present, there is no information on the effect of culture and race on eating disorders in

The risk of eating disturbances has been postulated to be higher in type 1 diabetic patients than in the general population due to multiple interacting factors related to diabetes and its treatment (Colton et al, 1999; Rodin & Daneman, 1992). Diabetes management imposes some degree of perceived dietary restraint, particularly patients who eat according to a predetermined meal plan, rather than in response to internal cues for hunger and satiety. Such neglect of internal cues may contribute to dietary dysregulation in susceptible individuals (Polivy & Herman, 1985). The relationship between higher weight and DEB presents a management dilemma for clinicians, since both dietary restraint and higher weight are clear risk factors for the development of ED and their negative health

Although until recently it has been unclear whether there is a specific association of eating disorders with diabetes, some studies have suggested an increased incidence of eating disorders in young women with diabetes (Birk & Spencer, 1987; Engstrom et al, 1999; Hudson et al, Lloyd et al, 1987; 1985; Rodin et al, 1985; Rodin et al, 1986/1987; Rodin et al, 1991; Rosmark et al, 1986; Stancin et al, 1989; Steel et al, 1987; Vila, et al, 1993; Vila et al, 1995) whereas others did not find such an increase (Bryden et al, 1999; Fairburn et al, 1991; Friedman et al, 1995; Mannucci et al, 1995; Marcus et al, 1992; Meltzer et al, 2001; Peveler et al, 1992; Powers et al, 1990; Robertson & Rosenvinge, 1990; Striegel-Moore et al, 1992; Wing et al, 1986). However, the conclusions of these studies are limited by the small sample sizes of females in the age of the highest risk for eating disturbances, the absence of control groups, their low statistical power, and/or by the lack of structured diagnostic interviews

A study examined the association between ED and type 1 diabetic girls, aged 12-19, for at least 1 year. Subjects with diabetes were 2.4 times more likely than non diabetic controls to have a clinical ED and 1.9 times more likely to have a subthreshold ED (Affenito & Adams, 2001). In another investigation, the prevalence of ED in a population-based cohort of female adolescents with type 1 diabetes was compared with that found in aged-matched controls. DEB was found in 16.9% of adolescents with diabetes compared with 2.2% of the controls (Hoek, 1993). A longitudinal study of 87 patients with diabetes aged at baseline 11-25 years, in whom eating habits and attitudes were assessed by a semistructured research diagnostic

**diabetic patients** 

people with diabetes.

consequences.

for the assessment of eating disorders.

interview, showed that 14.9%, at baseline, and 26%, at the end of the follow-up period, had evidence of bingeing or purging while insulin misuse for weight control was reported by 35.6% of the patients (Peveler et al, 2005). A recent study from France (Ryan et al, 2008) concluded that abnormal eating behavior is present in French diabetic patients at higher levels than among the general population.

Thus, nowadays, there is clear evidence that EB and DEB are more prevalent in type 1 diabetic women than in the general population.
