**11. Conclusions**

Diabetes self-management is crucial to prevent early morbidity. Although more experimental research is needed, especially in minority populations and the non-adolescent age range, the addition of coping skills training and problem solving interventions to the clinical care of patients with diabetes appears warranted. Such interventions can be incorporated into routine diabetes education programs or the content included in regular diabetes care visits. Interventions using coping skills training and problem solving for children, adolescents, and adults with diabetes and their families should be individualized to their lifestyle, respect individual differences and routines, incorporate social support, and be reinforced and followed over time. Behavioral theory should be used in the design of future approaches.

Today is well-known that disordered eating behaviors and subthreshold disordered eating disorders are more prevalent in girls with type 1 diabetes than their peers without diabetes. DEB persists over time and its rates and symptoms severity increase with age. In type 1 diabetic women, the predominant ED are BN and EDNOS. Furthermore, these patients also develop specific DEB such as diet restriction, and insulin misuse in order to lose weight, with the consequent impairment of their metabolic control which is followed by acute diabetic complications such as diabetic ketoacidosis, dehydration or electrolyte anomalies, and chronic microvascular complications, mainly diabetic retinopathy, that even increase the risk of mortality.

Full established DEB and ED are difficult to manage. The management of these conditions requires a multidisciplinary team formed by an endocrinologist/diabetologist, nurse educator, nutritionist, psychologist and, frequently, a psychiatrist who should be consulted to evaluate and treat with psycho pharmaceutical products the possible psychiatric comorbidities of these patients. Unfortunately, the mentioned team is often not available for patients.

The best psychological methods to treat these anomalies are not determined yet. According to personal experience, patients tend to be treated individually or in group and, frequently, it is needed familiar therapy. Results of the treatment of these entities from experienced health professionals are waiting.

The key for the management of type 1 diabetic patients with ED or DEB is the early diagnosis and treatment. Unfortunately, validated questionnaires to screen type 1 diabetic population are not available so far. Therefore it is important that the staff of the diabetes team who treats these patients should know the relationship between poor diabetes metabolic control and intentional misuse of insulin, or the recommended diet to control weight gain. They also should know that strict diet and intensive insulin regimens are risk factors for the development of DEB or ED. Therefore, it would be important to be alert to detect excessive concern about body weight, shape or body dissatisfaction in these patients. Eating disorders in type 1 diabetic patients represent some of the most complex patient

problems to treat both medically and psychologically. Given the extent of the problem and the severe medical risk associated with it, more clinical and technological research aimed to improve its treatment is critical to the future health of this at-risk population.
