Eating disorders in adolescent girls with insulin-dependent diabetes mellitus: a population-based case-control study

Prevalence of eating disorder symptoms in people with insulin-dependent-diabetes: A systematic review and meta-analysis

AIMS

To examine the prevalence of eating disorder symptoms (EDS) in 16 years and older individuals with insulin-dependent diabetes including both clinical and subclinical eating disorder symptoms.

METHODS

We searched PubMed, Embase, Scopus, PsycINFO, and CINAHL databases to discover studies reporting prevalence of eating disorder symptoms in patients with insulin-dependent diabetes (both type 1 and type 2). We performed a meta-analysis to estimate the pooled prevalence of eating disorder symptoms and an independent meta-analysis to estimate the prevalence of insulin omission.

RESULTS

A total of 45 studies were included in the meta-analysis of eating disorder symptoms. Diabetes Eating Problem Survey (DEPS-R) was the most frequently used screening tool (in 43 % of studies, n = 20). The pooled prevalence of eating disorder symptoms was 24 % (95 % CI 0.21-0.28), whereas in studies using DEPS-R, it was slightly higher, 27 % (95 % CI 0.24-0.31), with the prevalence ratio (PR) of 1.1. The prevalence differed between screening tools (χ2 = 85.83, df = 8, p < .0001). The sex distribution was associated with the observed prevalences; in studies with a higher female prevalence (>58 %), the pooled eating disorder symptom prevalence was higher [30 % (95 % CI 0.26-0.34) vs. 18 % (95 % Cl 0.14-0.22), PR 1.7]. The prevalence of insulin omission was 21 % (95 % CI 0.13-0.33).

CONCLUSIONS

Eating disorder symptoms and insulin omission are common in patients with insulin-dependent diabetes regardless of age. DEPS-R is the most used screening tool. Studies with a higher proportion of female participants report higher prevalence rates.

Associations between Disordered Eating Behaviors and HbA1c in Young People with Type 1 Diabetes: A Systematic Review and Meta-analysis

BACKGROUND

In type 1 diabetes, disordered eating behaviors (DEB) can adversely impact HbA1c. Diabetes-adapted DEB questionnaires assess intentional insulin omission, whereas generic questionnaires do not. Given the number of studies describing DEB-HbA1c associations published over the past decade, an updated systematic review is warranted.

OBJECTIVE

The study aimed to examine the associations between DEBs assessed by generic and diabetes- adapted questionnaires (and subscales) and HbA1c among young people (<29 years) with type 1 diabetes.

METHODS

A systematic search was conducted in PubMed, Embase, PsycInfo, and CINAHL databases. Observational studies examining associations between DEB as assessed by questionnaires and HbA1c were included. Publication information, DEB and HbA1c characteristics, and DEBHbA1c associations were extracted. Hedges' g was calculated for mean HbA1c differences between groups with and without DEB.

RESULTS

The systematic search yielded 733 reports, of which 39 reports representing 35 unique studies met the inclusion criteria. Nineteen studies assessing DEB by diabetes-adapted questionnaires (n=5,795) and seven using generic questionnaires (n=2,162) provided data for meta-analysis. For diabetes-adapted questionnaires, DEB was associated with higher HbA1c (g=0.62 CI=0.52; 0.73) with a similar effect size when restricted to validated questionnaires (g=0.61; CI=0.50; 0.73). DEB was not associated with HbA1c for generic questionnaires (g=0.19; CI=-0.17; 0.55), but significantly associated with higher HbA1c for validated generic questionnaires (g=0.32; 95% CI=0.16-0.48). Participant and HbA1c collection characteristics were often inadequately described.

CONCLUSION

Diabetes-adapted DEB questionnaires should be used in youth with type 1 diabetes because they capture intentional insulin omission and are more strongly associated with HbA1c than generic DEB questionnaires.

Psychological Alterations in Youths with Type I Diabetes: Associations with Salivary Cortisol Concentration

Background and Objectives: Type 1 diabetes mellitus (T1DM) is one of the most common chronic diseases in children and adolescents, and is associated with stress and other psychological alterations. This study aims to assess psychological and sleep disorders and health-related quality of life in young people with T1DM and to determine the relationship between these parameters and levels of salivary cortisol, a hormone widely associated with stress and several psychological symptoms. Materials and Methods: In our cross-sectional study performed in 60 Moroccan children and adolescents with T1DM, detailed psychological evaluations were performed to assess symptoms of anxiety, attention-deficit hyperactivity disorder (ADHD), sleep quality and diabetes-specific quality of life (using the RCMAS-2, ADHD rating scale, Pittsburgh scale and the DQoL scale, respectively), and cortisol concentration was measured from saliva samples taken mid-morning. Results: A total of 60 children and adolescents with T1DM were recruited. The mean age was 11.05 ± 0.35 (6-17). The mean salivary cortisol level in ng/mL was 4.7 ± 0.49 (0.7-20.2) and was significantly associated with an anxiety RCMAS2 score for the Worry subdomain and DQoL subdomain "Anxiety". Linear regression analysis showed that salivary cortisol was significantly higher in girls compared to boys (p = 0.004) (beta coefficient: 3.384 CI95%: 1.137-5.630) and with Hb1AC level as a continuous variable (p = 0.0001) (beta coefficient: 1.135 CI95%: 0.509-1.760). The other variables included in the model were not significant (p > 0.05). There was an association between salivary cortisol concentration with anxiety RCMAS2 score for Worry subdomain and QoL sub-domain "Anxiety". Still, a significant (p = 0.018) association emerged for anxiety RCMAS2 score Worry subdomain and QoL anxiety subdomain (p = 0.044). Conclusions: Children and adolescents with T1DM experienced significantly elevated symptoms of anxiety and sleep disturbances, particularly in girls, and frequent symptoms of ADHD, particularly in boys. Salivary cortisol concentration collected in the morning is associated with anxiety burden but not with other psychological alterations. Further studies are needed to clarify the associations between salivary cortisol concentration and anxiety in type 1 diabetes in order to propose the hormone as a biomarker for interventions aimed to reduce anxiety levels in these patients.

Prevalence of mental disorders in people living with type 1 diabetes: A systematic literature review and meta-analysis

OBJECTIVE

Type 1 diabetes is associated with increased prevalence of individual categories of mental disorders. We aimed to systematically synthesise the prevalence of all the different categories of mental disorders to estimate the overall burden of psychiatric morbidity in the type 1 diabetes population.

METHOD

The electronic database of OVID was searched, and retrieved papers were screened for eligibility by two independent reviewers. Data were extracted using a standardised data extraction form and the quality of included papers was assessed. Where possible, comparisons with control groups without type 1 diabetes were made. Prevalence data were synthesised into Diagnostic and Statistical Manual of Mental Disorders version 5 categories, a narrative data-synthesis, and a subsequent meta-analysis where possible was conducted for mental disorder categories.

RESULTS

Thirty-eight articles were included. Depressive, anxiety, and feeding and eating disorders were the most examined mental disorders. Studies utilising diagnostic interviews reported higher prevalence of mental disorders than in studies utilising clinical registers, with an up to 24-fold difference respectively. In studies with a control group, the prevalence for nearly every mental disorder were increased for the type 1 diabetes samples.

CONCLUSIONS

There appears to be a high prevalence of mental disorders and associated need among people with type 1 diabetes, although the quality of research needs to improve.

SYSTEMATIC REVIEW REGISTRATION

This protocol was submitted for registration with the International Prospective Register of Systematic Reviews (PROSPERO) (CRD42020221530).

Eating Disorders and Diabetes

PURPOSE OF REVIEW

This review describes the characteristics of patients with eating disorders in both type 1 and type 2 diabetes and the principles of their treatment.

RECENT FINDINGS

The combination of type 1 diabetes and an eating disorder is sometimes known as "diabulimia". The hallmark of the condition is that the patient deliberately takes an inadequate amount of insulin in order control their body weight (insulin restriction). Other disordered eating behaviours, such as dietary restriction, self-induced vomiting and binge eating, may also be present but typical anorexia nervosa is rare. There is an increased prevalence of eating disorders in adolescents with type 1 diabetes, which is estimated at 7%. The combination of type 1 diabetes and an eating disorder leads to elevated levels of HbA1c and an increased risk of both acute and chronic complications. Screening is recommended but rarely carried out. Management requires an understanding of the inter-relationships between eating behaviour, mood, blood glucose and insulin administration. Treatment aims to introduce a regular eating pattern and support the patient to increase their insulin dose gradually. Eating disorders also occur in those with type 2 diabetes, where binge eating disorder is the most common diagnosis. Eating disorders are common in both type 1 and type 2 diabetes, with an increased prevalence of complications in type 1. Treatment requires an understanding of both diabetes and eating behaviour.

Screening and identification of disordered eating in people with type 1 diabetes: A systematic review

People with Type 1 diabetes (T1D) have been shown to be an at-risk group for the development of disordered eating behaviours, however, the validity of tools used to assess disordered eating behaviours in T1D is unclear. This review aimed to identify tools used to screen or identify disordered eating behaviours and eating disorders in people with T1D, and evaluate the validity and reliability of these tools. A systematic search strategy was conducted to October 2019 according to the PRISMA guidelines. The search strategy retrieved 2714 articles, with 100 articles describing 90 studies included in the review. Studies were predominantly conducted in adolescent females in clinical settings. Forty-eight individual tools were used across retrieved studies. Overall, the quality of tools reported in included articles was poor, with high risk of bias due to the use of non-validated tools (n = 44 articles) and few studies comparing to the reference standard (n = 10 articles) of a diagnostic interview. This review shows that a variety of tools have been used to screen and identify disordered eating behaviours and eating disorders in people with T1D. Future research including comparison to a gold standard diagnostic interview is warranted to further evaluate the validity and reliability of available tools.

Disturbed Eating Behaviors in Adolescents and Emerging Adults With Type 1 Diabetes: A One-Year Prospective Study

OBJECTIVE

Disturbed eating behavior (DEB) is prevalent in youth with type 1 diabetes and is accompanied by an increased risk for complications, morbidity, and mortality. Prospective studies on DEB in the challenging transition to adulthood are scarce. This longitudinal study examined DEB over a 1-year period and investigated the directionality of effects linking DEB to diabetes-specific functioning and depressive symptoms in adolescents and emerging adults.

RESEARCH DESIGN AND METHODS

Three hundred youth (16-28 years old) with type 1 diabetes participated in a two-wave longitudinal study. Questionnaires measured DEB (Diabetes Eating Problem Survey-Revised [DEPS-R]), self-management, diabetes distress, and depressive symptoms. HbA_1c values were obtained from physicians. Mixed ANOVA and cross-lagged analysis were used to examine prospective changes and directionality of effects, respectively.

RESULTS

Mean DEB remained stable in the total sample, but significant individual differences were observed based on the cutoff score of the DEPS-R: 19% displayed persistent DEB and 8% increased and 7.3% decreased in DEB over time. The remaining individuals scored low on DEB over time. These four groups were differentiated based on insulin restriction, omission, diabetes-specific functioning, and depressive symptoms. Cross-lagged analyses indicated that DEB predicted relative increases in depressive symptoms over time, whereas reciprocal associations with glycemic control were found.

CONCLUSIONS

This longitudinal study highlights the substantial impact DEB may have in the transition to adulthood, with a substantial portion of youth with type 1 diabetes being at risk for clinical DEB. Prospective pathways linking DEB to functioning were found, emphasizing the clinical relevance of assessing DEB over time.

Are children with chronic illnesses requiring dietary therapy at risk for disordered eating or eating disorders? A systematic review

OBJECTIVE

Pediatric chronic illnesses (CI) can affect a child's mental health. Chronic illnesses with treatment regimens that specify a therapeutic diet may place the child at increased risk for disordered eating and specific eating disorders (ED). The aim of this review is to examine the relation between diet-treated CI and disordered eating and to determine the order of onset to infer directionality. Diet-treated CI is hypothesized to precede and to be associated with disordered eating.

METHOD

A comprehensive search of empirical articles that examine the relation between diet-treated CI (diabetes, cystic fibrosis, celiac disease, gastrointestinal disorders, and inflammatory bowel diseases) and disordered eating was conducted in Medline and PsycINFO using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A table of the sample's characteristics, ED measures, major pertinent findings, and the onset of CI in relation to ED were provided.

RESULTS

Diet-treated CI was associated with disordered eating and ED. Diet-treated CI had onset prior to disordered eating in most studies, except for inflammatory bowel diseases. Disordered eating and unhealthy weight management practices put children at risk for poor medical outcomes.

DISCUSSION

Interventions for diet-treated CI require a focus on diet and weight, but may increase the risk for disordered eating. Future research is needed to elucidate the mechanisms that transform standard treatment practices into pathological eating, including characteristics and behaviors of the child, parents/care providers, family, and treatment providers.

Disordered eating behaviour in young adults with type 1 diabetes mellitus

BACKGROUND

The combination of eating disorders and diabetes is associated with increased risk of morbidity and mortality. The aim of this study is to compare the prevalence of disordered eating behaviour (DEB) in young adults with type 1 diabetes mellitus to a sample of non-diabetic controls, and to examine the relationship of DEB to glycaemic control.

METHODS

The Eating Disorder Examination Questionnaire (EDE-Q) was administered to 51 individuals aged 18-30 years attending an outpatient diabetic clinic in a large university teaching hospital. Glycaemic control was assessed by the glycosylated haemoglobin (HbA1c). The control group comprised a consecutive sample of 236 male and female students aged 18-30 years attending a university primary health care service.

RESULTS

The mean global EDE-Q score for the diabetes group was 0.82 ± 1.1 (mean ± SD) and the mean for the control group was 1.4 ± 1.3 (mean ± SD). The diabetes group was significantly more likely to have a lower global EDE-Q score compared to the control group. There was no association between the global EDE-Q score of the diabetes group and HbA1c level.

CONCLUSIONS

We did not find increased levels of disordered eating behavior (DEB) in young adults with type 1 diabetes mellitus compared to a non-diabetic control sample.

Eating Disorders and Disordered Eating Symptoms in Adolescents with Type 1 Diabetes

Eating problems in adolescents with type 1 diabetes (T1D) can be divided into two groups. The first includes the diagnosed eating disorders (EDs), i.e., diseases specifically identified by defined signs and symptoms for which a degree of severity has been established, such as anorexia nervosa, bulimia nervosa, binge-eating disorder, pica, and rumination. The second is the group of disordered eating symptoms (DES), which include behaviors such as dieting for weight loss, binge eating, self-induced vomiting, excessive exercise, and laxative or diuretic use; these behaviors cannot be categorized as complete diseases, and, although apparently mild, they must be closely evaluated because they can evolve into true EDs. In this review, present knowledge about the clinical relevance of EDs and DES and the possible preventive and therapeutic measures used to reduce their impact on the course of T1D will be discussed. As adolescents with diabetes are at higher risk of eating disturbances and consequently for higher rates of disease complications, care providers should pay attention to clinical warning signs that raise suspicion of disturbed eating to refer these patients early to an expert in nutrition and mental health disorders. To ensure the best care for adolescents with T1D, diabetes teams should be multidisciplinary and include a pediatric diabetologist, a skilled nurse, a dietician, and a psychologist.

Autonomy and Submissiveness as Cognitive and Cultural Factors Influencing Eating Disorders in Italy and Sweden: An Exploratory Study

The aim of this exploratory study was to investigate the correlation between cultural and psychological factors in relation to predicting eating disorders in two different non-clinical Italian (n = 61) and Swedish (n = 31) female populations, thought to have different cultures and lifestyles. The Swedish sample would reflect an emancipated model of women pursuing autonomy and freedom but also an ideal of thinness, while the Italian sample would reflect a difficult transition from traditional submissiveness to modern autonomy. Both groups completed self-report instruments assessing cultural values (e.g., collectivism and individualism) and features of eating disorders (e.g., drive for thinness, bulimia, body dissatisfaction, self-esteem, parental criticism and perfectionism). Swedish women were found to display higher levels of bulimia, perfectionism, and individualism than Italian women, while regression analysis showed that in the Italian sample high levels of collectivism were correlated with measures of EDs. The results support the hypothesis that EDs are linked with both modern values of autonomy, independence and emancipation, and situations of cultural transition in which women are simultaneously exposed to traditional models of submission and opportunities for emancipation and autonomy.

Eating-Disordered Behaviour in Adolescents with Type 1 Diabetes

OBJECTIVES

To evaluate dysfunctional eating behaviour, self-esteem, social physique anxiety and quality of life in adolescents with type 1 diabetes who have differing desired weights and to evaluate the predictors of dysfunctional eating behaviour in these adolescents, with a focus on personal and psychological variables.

METHODS

We evaluated 79 adolescents with type 1 diabetes (mean age of 15.71 years) of both sexes (58.2% females) using the Eating Disorders Examination Questionnaire (EDE-Q), the Rosenberg Self-Esteem Scale (RSES), the Social Physique Anxiety Scale (SPAS-R) and the Diabetes Quality of Life (DQoL) measure.

RESULTS

Of the adolescents, 44 with type 1 diabetes reported the desire to maintain or increase their current weight, and 35 reported the desire to reduce their current weight. The participants with the desire to weigh less were mainly females who exercised regularly and demonstrated more frequent binge eating and purging. Additionally, this group exhibited an increased frequency of eating disturbances, such as restraint and eating, weight and shape concerns. Moreover, this group demonstrated increased social physique anxiety and decreased diabetes quality of life in relation to the impact of diabetes, worries about diabetes and satisfaction with life. Finally, predictors of eating disturbances included the desire for lower weight, higher social physique anxiety and lower diabetes-related quality of life.

CONCLUSIONS

The desire for a lower weight in adolescents with type 1 diabetes may increase problems related to eating behaviour and general quality of life.

Disordered eating and insulin restriction in youths receiving intensified insulin treatment: Results from a nationwide population-based study

OBJECTIVE

This Germany-wide population-based study sought to estimate the prevalence of disordered eating and insulin restriction (IR) among 819 youths aged 11-21 years with early-onset type 1 diabetes (T1D) and a disease duration of at least 10 years.

METHODS

All respondents answered the five-item SCOFF screening questionnaire for eating disorders (EDs) and reported on the frequency of IR and clinical outcomes. Screening for disordered eating was positive when more than two SCOFF items were answered affirmatively. Frequent IR was defined as IR occurring more than five times per week.

RESULTS

A total of 28.2%/9.2% of the female/male patients were SCOFF-positive without IR and 4.2%/5.3% reported frequent IR but were SCOFF-negative; 2.7%/1.9% screened positive for both disordered eating and IR. Patients with disordered eating, frequent IR, or both showed significantly worse glycemic control and partly more inpatient-treated diabetic ketoacidoses than patients who screened negative.

DISCUSSION

Approximately one in three female and one in six male patients with early-onset long-duration T1D reported disordered eating and/or frequent IR. Because of their association with worse outcomes, both disordered eating and IR should be considered in T1D care irrespective of sex, age at onset, and diabetes duration.

Stressful task increases drive for thinness and bulimia: a laboratory study

The scientific literature has suggested that stress undergirds the development of eating disorders (ED). Therefore, this study explored whether laboratory induced stress increases self-reported drive for thinness and bulimic symptoms measured via self-report. The relationship between control, perfectionism, stress, and cognition related to ED was examined using correlational methodology. Eighty-six participants completed an experimental task using a personal computer (PC). All individuals completed a battery of tests before and after the stressful task. Analyses showed a significant statistical increase in average scores on the drive for thinness and bulimia measured before and after a stressful task, and path analysis revealed two different cognitive models for the mechanism leading to drive for thinness and bulimia. These findings suggest that stress is an important factor in the development of the drive for thinness and bulimia.

Topical review: a comprehensive risk model for disordered eating in youth with type 1 diabetes

OBJECTIVES

Provide an updated literature review on prevalence, measurement, and correlates of disordered eating in youth with Type 1 diabetes (T1D), present a novel theoretical risk model (i.e., The Modified Dual Pathway Model) for disordered eating in youth with T1D incorporating psychosocial and physiological risk factors, and discuss clinical implications.

METHODS

Literature review of prevalence, correlates, risk factors, and outcomes of disordered eating behavior (DEB) in youth with T1D.

RESULTS

Insulin treatment, subsequent weight gain, and disruptions to hunger and satiety regulation are hypothesized disease-related mechanisms through which the treatment of T1D may increase vulnerability to development of behavior characterized as DEB. The Modified Dual Pathway Model integrates these factors with a validated psychosocial risk (body dissatisfaction, depression, and abstinence violation) model for DEB in nondiabetic youth.

CONCLUSIONS

The Modified Dual Pathway model of DEB in youth with T1D is a comprehensive representation of both psychosocial and T1D-related risk factors with the potential to inform future interventions for this population.

Eating disorders in adolescents with type 1 diabetes: Challenges in diagnosis and treatment

Eating disorders (ED) are characterized by a persistent disturbance of eating that impairs health or psychosocial functioning. They are associated with increased rates of medical complications and mortality. Insulin omission is a unique purging behavior available to individuals with type 1 diabetes mellitus (T1DM). The standard treatment regimen for T1DM requires a major focus on food and eating patterns. Moreover, intensive insulin therapy is associated with increasing body weight. These factors, combined with the psychological burden of chronic disease management and depression, may contribute to ED. The comorbidity of ED in T1DM patients is associated with poorer glycemic control and consequently higher rates of diabetes complications. Early recognition and adequate treatment of ED in T1DM is essential.

Is disordered eating behavior more prevalent in adolescents with early-onset type 1 diabetes than in their representative peers?

OBJECTIVE

Despite modern therapeutic regimens, youths with Type 1 diabetes may be at increased risk of mental and behavioral disorders. In this study, the prevalence of disordered eating behavior (DEB) in intensely treated children and adolescents with early-onset Type 1 diabetes and peers from the general population was compared.

METHOD

Data from 629 patients from a population-based, nationwide survey (54.1% male, mean age 15.3 years) with early-onset Type 1 diabetes of at least 10 years duration were compared with data from 6,813 participants of the German KiGGS study (51.3% male, mean age 14.6 years). The generic SCOFF questionnaire was used as screening instrument to identify participants with symptoms of DEB. Both groups were compared with multivariable regression analysis adjusting for sociodemographic covariates.

RESULTS

31.2% of the female and 11.7% of the male diabetic patients and 28.9% of the females and 15.2% of the males in the comparison group were SCOFF-positive (SCOFF score ≥2; p > .05). The odds for symptoms of eating disorders were 3.7% higher in female and 4.3% lower in male patients with diabetes than in the comparison group, but the differences were not significant. 20.5% of the female and 18.5% of the male diabetic patients reported insulin restriction at least three times per week.

DISCUSSION

Children and adolescents with early-onset Type 1 diabetes of long duration do not seem to be more frequently SCOFF-positive than peers. However, as insulin restriction is practiced in a substantial portion of patients, attention for insulin restriction in diabetes care is essential.

Emotional dysregulation and anxiety control in the psychopathological mechanism underlying drive for thinness

Emotional dysregulation is a process which consists in mitigating, intensifying, or maintaining a given emotion and is the trigger for some psychological disorders. Research has shown that an anxiety control plays an important role in emotional expression and regulation and, in addition, for anorexia nervosa (AN) and, more in general, in drive for thinness. Scientific literature suggests that in AN there is a core of emotional dysregulation and anxiety control. The aim of this study is to explore the roles of emotional dysregulation and anxiety control as independent or third variables in a mediational regression model related to drive for thinness. One hundred fifty-four clinical individuals with anorexia participated in the study and all completed a set of self-report questionnaires: eating disorders inventory version 3 (EDI-3), DERS, and the anxiety control questionnaire. The data confirmed a mediational model in which the relation between emotional dysregulation and drive for thinness is mediated by anxiety control. The current study partially supports a clinical model in which emotional dysregulation is a distal factor in eating disorders while the mediator variable anxiety control is a proximal factor in the psychopathological process underlying it.

Disturbed eating behavior and omission of insulin in adolescents receiving intensified insulin treatment: a nationwide population-based study

OBJECTIVE

To establish the prevalence of disturbed eating behavior (DEB) and insulin omission among adolescents with type 1 diabetes using intensive insulin treatment in a nationwide population-based study.

RESEARCH DESIGN AND METHODS

The Diabetes Eating Problem Survey-Revised (DEPS-R) is a diabetes-specific screening tool for DEB. Clinical data and HbA1c were obtained from the Norwegian Childhood Diabetes Registry.

RESULTS

A total of 770 children and adolescents 11-19 years of age with type 1 diabetes completed the DEPS-R. A total of 27.7% of the females and 8.6% of the males scored above the DEPS-R cutoff. Participants scoring above the cutoff had significantly higher HbA1c (9.2% [77 mmol/mol]; SD, 1.6) than participants scoring below the cutoff (8.4% [68 mmol/mol]; SD, 1.3; P < 0.001). The prevalence of DEB increased significantly with age and weight, from 7.2% in the underweight group to 32.7% in the obese group, and from 8.1% in the youngest age-group (11-13 years) to 38.1% in the oldest age-group (17-19 years). A total of 31.6% of the participants reported insulin restriction and 6.9% reported insulin omission after overeating. Patients reporting insulin restriction had significantly higher HbA1c (9.0% [75 mmol/mol]; SD, 1.7) than nonrestrictors (8.3% [67 mmol/mol]; SD, 1.2; P < 0.001).

CONCLUSIONS

One-fourth of girls with type 1 diabetes scored above the cutoff for DEB and one-third reported skipping their insulin dose entirely at least occasionally after overeating. Both DEB and insulin restriction were associated with poorer metabolic control, which may increase the risk of serious late diabetes complications.

Demographic and personal factors associated with metabolic control and self-care in youth with type 1 diabetes: a systematic review

Optimal use of recent technological advances in insulin delivery and glucose monitoring remain limited by the impact of behaviour on self-care. In recent years, there has been a resurgence of interest in psychosocial methods of optimizing care in youth with type 1 diabetes. We therefore sought to examine the literature for demographic, interpersonal and intrapersonal correlates of self-care and/or metabolic control. Studies for this systematic review were obtained via an electronic search of Medline, Embase, Cumulative Index to Nursing and Allied Health Literature and PsycINFO databases. Seventy studies fulfilled the inclusion criteria. These studies have indicated that identifiable individual characteristics in each domain are robustly associated with metabolic control and/or self-care in children and adolescents. We present these characteristics and propose a theoretical model of their interactions and effect on diabetes outcomes. There is currently no consensus regarding patient selection for insulin pump therapy. In this era of scarce healthcare resources, it may be prudent to identify youth requiring increased psychosocial support prior to regimen intensification. The importance of this review lies in its potential to create a framework for rationally utilizing resources by stratifying costly therapeutic options to those who, in the first instance, will be most likely to benefit from them.

Disturbed eating behaviours and thoughts in Australian adolescents with type 1 diabetes

AIM

To describe the presence and type of disturbed eating behaviours and thoughts in a combined male/female Australian sample of adolescents with type 1 diabetes, and examine the association of eating behaviours and thoughts with glycaemic control as evidenced by high glycosylated haemoglobin levels (HbA1c).

METHODS

In this cross-sectional descriptive study, 124 adolescents aged 13-18  years were invited to complete three self-administered questionnaires. The Youth Eating Disorder Examination Questionnaire (YEDE-Q) and the Eating Disorder Inventory -3 Risk Composite (EDI-3RC) assessed risk for an eating disorder. The third questionnaire, the Strengths and Difficulties Questionnaire (SDQ) assessed emotional and behavioural concerns. Clinical data were collected from the medical records, routine clinic appointments and the adolescent.

RESULTS

Any disturbed eating behaviour was reported by approximately one-third of participants (32.3%) and was common in females and males (37.9% vs. 25.9%). Binge eating (17.7%), driven exercise (13.0%) and dietary restraint (8.9%) were the most common disturbed eating behaviours, although restraint was not evident in males. Insulin manipulation/omission (5.6%), vomiting (3.3%), laxative (0.8%) or diuretic use (0.8%) were less common. Regression analysis showed a significant association between HbA1c and more disturbed eating behaviours and thoughts which remained significant when adjusted for confounders.

CONCLUSIONS

High rates of disturbed eating behaviours and thoughts were seen in this Australian sample of adolescents with type 1 diabetes. High scores on both eating disorder measures were associated with poorer glycaemic control. These results highlight the need to screen for disordered eating in adolescents with type 1 diabetes.

Eating problems in adolescents with Type 1 diabetes: a systematic review with meta-analysis

AIMS

We report a systematic review to determine (1) prevalence of eating problems compared with peers and (2) the association between eating problems and glycaemic control in young adults with Type 1 diabetes.

METHOD

  We conducted a systematic literature search via electronic databases and meta-analysis. Cohen's d (the mean difference score between Type 1 diabetes and comparison groups) was calculated for 13 studies that met inclusion criteria.

RESULTS

  Eating problems [both disordered eating behaviour (39.3 and 32.5%; d = 0.52, 95% CI 0.10-0.94) and eating disorders (7.0 and 2.8%; d = 0.46, 95% CI 0.10-0.81)] were more common in adolescents with Type 1 diabetes compared with peers and both were associated with poorer glycaemic control (d = 0.40, 95% CI 0.17-0.64). In restricted analyses involving measures adapted for diabetes, associations between eating problems and poorer glycaemic control remained (d = 0.54, 95% CI 0.32-0.76). Disordered eating behaviour (51.8 and 48.1%; d = 0.06, 95% CI -0.05 to 0.21) and eating disorders (6.4 and 3.0%; d = 0.43, 95% CI -0.06 to 0.91) were more common in adolescents with Type 1 diabetes compared with peers, but differences were non-significant.

CONCLUSIONS

  Eating problems are common among this age group. Future work in populations with Type 1 diabetes should develop sensitive measures of eating problems and interventions, and establish predictors of eating problems. Screening in clinics is recommended.

Concurrent validity of self-report measures of eating disorders in adolescents with type 1 diabetes

AIM

Eating disorder screening tools have not been adequately validated for use with adolescents with type 1 diabetes. This study compared the Youth Eating Disorder Examination-Questionnaire (YEDE-Q) and the Eating Disorder Inventory-3 Risk Composite (EDI-3RC) against the child Eating Disorder Examination (chEDE). These screening tools were chosen because they broadly assess eating disorder psychopathology and have subscales helpful for clinical management.

METHODS

In this cross-sectional study, 124 adolescents with type 1 diabetes aged 13-18 years completed two self-administered questionnaires, the YEDE-Q and the EDI-3RC. Cronbach's alpha was used to assess internal consistency of the tools. Fifty-one adolescents, randomly selected, participated in the chEDE. Intraclass correlations and Spearman's correlations were used to measure concordance of the chEDE with the YEDE-Q and EDI-3RC.

RESULTS

The YEDE-Q and EDI-3RC demonstrated good subscale internal consistency; Cronbach's alpha for YEDE-Q (0.78-0.95) and EDI-3RC (0.79-0.94). High levels of concurrent validity with the chEDE were seen with both tools.

CONCLUSION

Preliminary evidence is provided for the validation of the YEDE-Q and EDI-3RC for use in adolescents with type 1 diabetes. The YEDE-Q also defines individual disturbed eating behaviours with frequency ratings which can be helpful for tailoring early intervention.

Empagliflozin, a novel potent and selective SGLT-2 inhibitor, improves glycaemic control alone and in combination with insulin in streptozotocin-induced diabetic rats, a model of type 1 diabetes mellitus

AIM

Sodium glucose cotransporter-2 (SGLT-2) is key to reabsorption of glucose in the kidney. SGLT-2 inhibitors are in clinical development for treatment of type 2 diabetes mellitus (T2DM). The mechanism may be of value also in the treatment of type 1 diabetes mellitus (T1DM). This study investigated effects of the SGLT-2 inhibitor, empagliflozin, alone and in combination with insulin, on glucose homeostasis in an animal model of T1DM.

METHODS

Sprague-Dawley rats were administered a single intraperitoneal injection of streptozotocin (STZ; 60 mg/kg). Acutely, STZ rats received two doses of insulin glargine with or without empagliflozin, and blood glucose was measured. In a subchronic study, STZ rats received empagliflozin alone, one or two insulin-releasing implants or a combination of one implant and empagliflozin over 28 days; blood glucose and HbA(1c) were measured.

RESULTS

In the acute setting, empagliflozin in combination with 1.5 IU insulin induced a similar glucose-lowering effect as 6 IU insulin. Both interventions were more efficacious than monotherapy with 1.5 IU insulin. In the subchronic study, 12-h blood glucose profile on day 28 in the combination group was lower than with one implant, and similar to two implants. Plasma HbA(1c) was improved in the combination group and in animals with two implants.

CONCLUSIONS

Empagliflozin reduced blood glucose levels in a T1DM animal model. Empagliflozin combined with low-dose insulin showed comparable glucose-lowering efficacy to treatment with high-dose insulin. Our data suggest that empagliflozin is an efficacious adjunctive-to-insulin therapy with the clinical potential for the treatment of T1DM.

Comorbid Diabetes and Eating Disorders in Adult Patients

Purpose

The lack of research concerning treatment for individuals with diabetes mellitus (DM) and comorbid eating disorders (ED) contributes to the gulf between the psychosocial needs of individuals with the two conditions and the treatment they receive. Empirical evidence has established that the prognosis of patients with this comorbid diagnosis (ED-DM) is poor in the absence of a specialized DM treatment specifically adapted to ED. In individuals with DM, comorbid ED is associated with numerous complications. Despite these interactions, current knowledge about the comorbid diagnosis is limited, and eating disorders in patients with diabetes often remain undiagnosed. This article presents standard procedures for assessment and optimal therapeutic interventions for patients with ED and DM.

Conclusion

In patients with diabetes, problematic eating behaviors and symptoms should be assessed routinely. When an eating disorder is detected, diabetes management needs to be adapted, binge eating or medication misuse needs to be addressed, and eating disorder specialists should be included in the multidisciplinary team.

The clinical biochemistry of anorexia nervosa

In anorexia nervosa, under-nutrition and weight regulatory behaviours such as vomiting and laxative abuse can lead to a range of biochemical problems. Hypokalaemia is the most common electrolyte abnormality. Metabolic alkalosis occurs in patients who vomit or abuse diuretics and acidosis in those misusing laxatives. Hyponatraemia is often due to excessive water ingestion, but may also occur in chronic energy deprivation or diuretic misuse. Urea and creatinine are generally low and normal concentrations may mask dehydration or renal dysfunction. Abnormalities of liver enzymes are predominantly characterized by elevation of aminotransferases, which may occur before or during refeeding. The serum albumin is usually normal, even in severely malnourished patients. Amenorrhoea is due to hypogonadotrophic hypogonadism. Reduced concentrations of free T4 and free T3 are frequently reported and T4 is preferentially converted to reverse T3. Cortisol is elevated but the response to adrenocorticotrophic hormone is normal. Hypoglycaemia is common. Hypercholesterolaemia is a common finding but its significance for cardiovascular risk is uncertain. A number of micronutrient deficiencies can occur. Other abnormalities include hyperamylasaemia, hypercarotenaemia and elevated creatine kinase. There is an increased prevalence of eating disorders in type 1 diabetes and the intentional omission of insulin is associated with impaired metabolic control. Refeeding may produce electrolyte abnormalities, hyper- and hypoglycaemia, acute thiamin depletion and fluid balance disturbance; careful biochemical monitoring and thiamin replacement are therefore essential during refeeding. Future research should address the management of electrolyte problems, the role of leptin and micronutrients, and the possible use of biochemical markers in risk stratification.

The relationship between alexithymia and maladaptive perfectionism in eating disorders: a mediation moderation analysis methodology

OBJECTIVE

This work aimed to explore the relationship between alexithymia and maladaptive perfectionism in the psychological process leading to eating disorders (ED).

METHOD

Forty-nine individuals with ED and 49 controls completed the Concern over Mistakes subscale of the Frost Multidimensional Perfectionism Scale, the Perfectionism subscale of the Eating Disorders Inventory, the total score of the Toronto Alexithymia Scale, and the Drive for Thinness, Bulimia, and Body Dissatisfaction subscales of the Eating Disorders Inventory. We tested a model in which alexythimia is the independent variable and perfectionism is the possible mediator or moderator.

RESULTS

Analyses confirmed the assumed model. In addition, it emerged that perfectionism played a mediating or moderating role when measured by different instruments. This result suggested that different instruments measured subtly different aspects of the same construct.

DISCUSSION

Results could suggest that alexithymia is a predisposing factor for perfectionism, which in turn may lead to the development of eating disorders.

Perfectionism as a mediator between perceived criticism and eating disorders

OBJECTIVE

In this work we aimed to test the hypothesis that perfectionism plays a third variable role in the psychological process leading from perceived criticism to eating disorders (ED).

METHOD

Forty-nine individuals with ED and 49 controls completed the Concern over Mistakes subscale of the Multidimensional Perfectionism Scale, the Perceived Criticism Inventory, and the Drive for Thinness, Bulimia, and Body Dissatisfaction subscales of the Eating Disorders Inventory. Mediational and moderational models were tested.

RESULTS

Analyses revealed that perfectionism mediates between perceived criticism and drive for thinness. Results for bulimia and body dissatisfaction were controversial. Moderational models were rejected.

DISCUSSION

Results suggest that restrictive dieting is related to a process in which perceived criticism is the initial factor and perfectionism is an intervening mediator.

Characteristics of self-regulation in adolescent girls with type 1 diabetes with and without eating disorders: a cross-sectional study

OBJECTIVES

Pathology of the regulative mechanisms of self seems to be connected with eating disorders (EDs). The present study aimed to explore the hypothesis that there are differences in self-regulation in adolescent girls with Type 1 diabetes with and without EDs.

DESIGN

A cross-sectional design was employed comparing patterns of self-regulation in adolescent girls with Type 1 diabetes with and without EDs in two eating status groups.

METHODS

For the presence of EDs, 76 adolescent girls with Type 1 diabetes were assessed. Of these, 23 were diagnosed with an ED. In addition, dimensions of self-regulation as conceptualized in terms of Kohuts' psychodynamic theory of self were assessed.

RESULTS

Adolescent girls with Type 1 diabetes and an ED were higher in three aspects of self-regulation - negative body self, object depreciation, and narcissistic gain from illness - in comparison with their peers without EDs.

CONCLUSIONS

This study is the first to show evidence of deficits in self-regulation in adolescent girls with Type 1 diabetes and EDs. The importance of evaluating parameters of self-regulation for treatment planning for these youths is outlined.

Obesity and eating disturbances are common in 15-year-old adolescents. A two-step interview study

A two-step interview study of eating disorders (EDs) and sub-clinical EDs in 15-year-old adolescents was carried out in western Finland. The sample consisted of all ninth graders in a well-defined catchment area (n=606, 98.2% of eligible students). In the first step, a self-report questionnaire was administered at schools regarding mental health problems and life circumstances. The questions concerning anorectic and bulimic eating pathology were formulated according to the DSM-IV diagnostic criteria of EDs. The second step consisted of a semi-structured interview Rating of Anorexia and Bulimia-Teenager version (RAB-T) to which 128 subjects were invited, on the basis of their answers to questions about eating pathology in the questionnaire. The participation rate in the interview was 88.3%. The lifetime prevalence rate for anorexia nervosa (AN) in 15-year-old girls was 1.8% and the point prevalence rate 0.7%. No cases of AN were found among the boys. All criteria fulfilling cases of bulimia nervosa (BN) were not found in our sample. High rates of AN not otherwise specified (AN-NOS; 4.9%) and sub-clinical EDs (4.9%) were found among the girls; 6.7% of girls and 0.6% of boys were regarded as being "at risk" of developing EDs. Data on height and weight are based on current measurements taken at school healthcare; 22% of boys were overweight or obese compared with 16% of girls.

Behavioral medicine interventions in diabetes

PURPOSE OF REVIEW

Poor glycemic control is prevalent in the majority of patients with diabetes and has a strong impact on medical as well as psychological outcomes. Psychological and behavioral variables are of particular interest, as the patients themselves are the most determining factor of treatment success. Consequently, a wide range of behavioral medicine interventions are aimed at improvement in diabetes self-management, coping strategies, blood glucose awareness, and stress reduction. This review provides an overview of randomized controlled trials (RCTs) published in the past 18 months (from March 2008 to September 2009) that evaluated behavioral medicine interventions in patients with diabetes. The review summarizes the interventions' effects on metabolic control and other medical variables, as well as diabetes self-management and psychological outcomes.

RECENT FINDINGS

Behavioral medicine interventions in the diabetes field encompass a number of different approaches with the goal of improving medical outcomes such as glycemic control as well as psychological outcomes. There is evidence for beneficial effects of recent behavioral medicine treatments in terms of improvement of metabolic control as indicated by decreased glycated hemoglobin (HbA1c). Furthermore, positive effects were observed regarding diabetes-related self-efficacy, self-management, proactive coping, and the reduction of psychological burdens and symptoms.

SUMMARY

Behavioral medicine interventions are effective in diabetes treatment, especially in patients with a high level of diabetes-related distress, difficulty in coping, or insufficient blood glucose awareness.

A cross-cultural comparison of the Eating Disorder Inventory

OBJECTIVE

A systematic analysis of data collected with the Eating Disorder Inventory (EDI) was made.

METHOD

A literature search identified 94 sources in which the mean values of the EDI or EDI-2 subscales were reported, comprising 310 samples differing by sex, age, diagnosis, language, ethnicity, or some other relevant attribute. The total number of respondents was 43,722, from 25 different countries, having used the EDI in one of the 16 languages (1-94).

RESULTS

The factorial structure of the aggregate means of the EDI subscales, for both clinical versus nonclinical and Western versus non-Western samples, was almost identical suggesting generalizability across languages and cultures. Non-Western participants scored higher than Western participants on virtually all EDI subscales, both in normal and eating-disordered samples. It was shown that age is a risk factor when someone is already diagnosed with an eating disorder but, in the general population, increasing age reduces the likelihood of being afflicted by eating disorders.

DISCUSSION

Symptoms of eating disorders are more pronounced in non-Western than in Western samples.

Disturbed eating behaviors in Taiwanese adolescents with type 1 diabetes mellitus: a comparative study

OBJECTIVES

This study aimed to (i) compare disturbed eating behaviors in adolescents with type 1 diabetes mellitus (T1D) with a matched group of adolescents in Taiwan and (ii) examine the relationships of disturbed eating behaviors to body mass index (BMI) and metabolic control among adolescents with T1D.

METHODS

A cross-sectional study was conducted in southern Taiwan. Seventy-one adolescents with T1D (aged 10-22 yr; 41 females and 29 males) were matched to a group of non-diabetic adolescents. Adolescents completed two self-reported measures of eating behavior, the Bulimic Investigatory Test, Edinburgh and the Eating Attitude Test-26. Metabolic control was assessed by glycosylated hemoglobin A1c levels.

RESULTS

Both adolescent females and males with T1D had more symptoms of bulimia and bulimic behaviors than their non-diabetic peers. There were no group differences in the proportion of subthreshold eating disorders. BMI and metabolic control were significant factors predicting disturbed eating behaviors.

CONCLUSIONS

Both adolescent females and males with T1D exhibited a higher level of disturbed eating behaviors than their non-diabetic adolescent counterparts. Preventive programs that address disturbed eating behaviors should be provided for adolescents with T1D, particularly for adolescents with a high BMI and poor metabolic control.

Low perception of control as a cognitive factor of eating disorders. Its independent effects on measures of eating disorders and its interactive effects with perfectionism and self-esteem

OBJECTIVE

There is a large body of research about perfectionism and low self-esteem in eating disorders (ED). However, little is known about the influence in ED of a distorted cognition in the domain of control: the perception of low control. The present study examined the main and interactive effects of concern over mistakes (an important dimension of perfectionism), self-esteem, and perception of control on drive for thinness, bulimia, and body dissatisfaction.

METHOD

Forty individuals with ED and 55 controls completed the Multidimensional Perfectionism Scale, the Anxiety Control Questionnaire, the Rosenberg self-esteem scale, and the three symptomatic scales of the Eating Disorder Inventory, which are drive for thinness, bulimia and body dissatisfaction. Multiple linear regression was used to test the hypothesis that perception of low control has a significant effect on the symptomatic scales of the EDI.

RESULTS

The ED group had significantly lower perception of control and self-esteem and higher concern over mistakes, drive for thinness, bulimia, and body dissatisfaction than the control group. Analysis of interactive effects suggested that a combination of a low perception of control and a low self-esteem seems to moderate the effects of concern over mistakes on drive for thinness, bulimia, and body dissatisfaction.

DISCUSSION

ED are associated with a tendency to worry about mistakes, a low sense of self-esteem, and a low perception of control over internal feelings and external events. Perception of control and self-esteem seems to moderate the predictive power of concern mistakes on symptoms of ED. The results suggest that a low perception of control is an important cognitive factor in ED.

The prevalence of abnormal eating behaviour in a representative sample of the French diabetic population

AIM

To assess the relationship between abnormal eating behaviour (AEB) and diabetes in a sample of French adult patients with type 1 (T1D) and type 2 (T2D) diabetes.

METHODS

Ninety-four consecutively recruited patients self-completed a series of validated questionnaires.

RESULTS

Over one-fourth of men with T1D (26%) or T2D (27%) and 11% of female T2D patients reported consistent and pathological overeating or binge-eating during the previous six months. Glycaemic control in these T1D patients was poorer than in T1D patients defined as normal eaters (NORM) (11.9% versus 9.6%), but did not reach statistical significance (P=0.08), and no significant difference was observed in the T2D group (P=0.61) either. T2D patients reported being markedly more restrained when eating than did the T1D patients (P=0.002), and their restraint increased along with their BMI (P<0.001). Patients who overate or binged also reported greater general hunger (P=0.02) and disinhibition (P=0.003) than did the NORM patients.

CONCLUSION

AEB is present in French diabetic patients at levels that are probably higher than among the general population. These results highlight the need for: (1) greater awareness among diabetes clinicians of the problem; (2) regular screening of diabetic patients for AEB; and (3) adaptation of therapeutic and dietary recommendations for this patient subgroup.

The influence of stress on the relationship between cognitive variables and measures of eating disorders (in healthy female university students): a quasi-experimental study

OBJECTIVE

Perfectionism, poor self-esteem and stress have all been described as important risk factors for eating disorders. The purpose of this study was to assess whether a stressful situation is significantly correlated to and associated with significantly higher levels of perfectionism, stress, quantifiable measures of eating disorders, and with significantly lower levels of self-esteem in a non-clinical sample.

METHOD

Thirty-five female university students completed the Multidimensional Perfectionism Scale, the Rosenberg Self-Esteem Scale, the Perceived Stress Scale, and the Eating Disorder Inventory two times; once on an average university day and once on the day of an exam. Descriptive statistics and t-tests were calculated to verify whether a stressful situation was associated with a significant difference in levels of perfectionism, self-esteem, stress, and measures of eating disorders. Bivariate correlations were calculated for both the stress and non-stress situation, to observe how the dimensions of perfectionism, self-esteem, and stress were associated with measures of eating disorders.

RESULTS

During the stress situation, the study participants had, on average, significantly higher levels of concern over mistakes, body dissatisfaction, drive for thinness, and perceived stress. Bivariate correlations revealed that during the stress situation perceived stress, cognitive variables and measures of eating disorders showed significant correlations with each other that were absent in the non stress situation.

DISCUSSION

The results of the present study suggest that the dimensions of pathological perfectionism, low self-esteem, and perceived stress are related to an increase in dieting thoughts and dissatisfaction with body aspect in non-clinical women during a performance that could potentially challenge the perception of their self-esteem. The stressful situation can be interpreted as an experience of invalidation, which could explain the connection between cognitive constructs and behaviours related to eating disorders.

Disordered eating and body dissatisfaction in adolescents with type 1 diabetes and a population-based comparison sample: comparative prevalence and clinical implications

OBJECTIVE

To compare the prevalence of disordered eating and body dissatisfaction between adolescents with type 1 diabetes and a population-based sample of youth.

SUBJECTS

A clinic-based sample of 143 adolescents (73 male and 70 female) with type 1 diabetes who participated in the Assessing Health and Eating among Adolescents with Diabetes (AHEAD) study was compared with a population-based sample of 4746 youths (2377 male, 2357 female, and 12 missing) who participated in Project Eating Among Teens (Project EAT).

METHOD

Participants completed surveys and anthropometric measurements of height and weight.

RESULTS

Although some adolescents with type 1 diabetes endorsed unhealthy weight control practices, overall, they reported less weight dissatisfaction and were less likely to use any unhealthy weight control behaviors and more likely to report regular meal consumption than the population-based sample. Females with type 1 diabetes were less likely to report dieting, fasting, or eating very little food to control weight during the past year than their population-based peers. However, males with type 1 diabetes were less likely than their peers to exercise and to consume more fruits and vegetables for healthy weight control. Of medical concern were insulin omission (1.4% males and 10.3% females) and dosage reduction (1.4% males and 7.4% females) as means of weight control among youth with type 1 diabetes.

CONCLUSIONS

Despite medical supervision, some adolescents with type 1 diabetes reported unhealthy weight control behaviors and weight concerns, including insulin manipulation. Altering the insulin regimen may cause complications. All adolescents warrant attention for unhealthy behaviors and weight concerns.

Obesity, hypertension, and mental health evaluation in adolescents: a comprehensive approach

The global epidemic of childhood and adolescent obesity in developing and developed countries has become a major public health concern. Given the relation between obesity and hypertension as documented in several landmark studies, it is no surprise that as the prevalence of obesity has increased in the pediatric population, the rates of hypertension have also increased substantially. Hypertension is one of the most important risk factors for cardiovascular diseases and stroke; therefore, evaluation and initiation of appropriate treatment are extremely important in the pediatric population. Evaluation for secondary causes of hypertension, including renovascular, renoparenchymal, and endocrine disease is the approach most commonly used in healthcare settings, with the goal to detect abnormalities that already have or might, if left unrecognized, affect the physical health of the child in the future. Children and adolescents are commonly evaluated for organic disease even in situations in which secondary hypertension is unlikely and overweight or obesity is most likely the primary factor contributing to hypertension. Psychological and psychosocial factors, which may play an important role in the etiology of obesity and related blood pressure elevation, are often addressed inadequately or completely ignored, potentially reducing long-term therapy success and increasing the incidence of avoidable complications. It is proposed that a comprehensive evaluation by a behavioral health provider will improve outcomes and potentially reduce long-term morbidity and hypertension-related end organ disease. A framework for mental health evaluation is provided.

Disordered eating behaviors in youth with type 1 diabetes

Eating disorders are a significant health problem for many adolescents and are described as occurring along a spectrum of symptoms including disordered eating behaviors and clinical eating disorders. Poor self-esteem and body image, intense fear of gaining weight or refusal to maintain weight, and purging unwanted calories are clinical features of some eating disorders. Type 1 diabetes is a chronic illness with marked insulin deficiency. Chronic hyperglycemia creates a state of glucosuria with subsequent weight loss. Diabetes treatment focuses on intensive daily management of blood glucose by balancing insulin, food intake, and physical activity. Insulin omission offers an easy method for the purging of unwanted calories. The combination of these 2 illnesses is potentially deadly and also leads to an increased risk of poor diabetes outcomes. This includes poor metabolic control (measured by elevated hemoglobin A1C), increased risk of diabetic ketoacidosis, and microvascular complications such as retinopathy and nephropathy. Diabetes clinicians should be aware of the potential warning signs in an adolescent with diabetes as well as assessment and treatment options for eating disorders with concomitant type 1 diabetes. This article reviews the available data on the prevalence, screening tools, assessment guidelines, and treatment options for eating disorders in youth with type 1 diabetes.

Disordered eating behaviors among Turkish adolescents with and without Type 1 diabetes

The aim of this comparative study was to determine the prevalence of disordered eating behaviors (DEBs) and its affecting factors among adolescents with Type 1 diabetes. Subjects were 45 diabetic adolescents and 55 nondiabetic healthy control subjects. The main outcome measures used were the Eating Attitudes Test and the Body Image Scale (BIS). Findings suggest that DEBs are almost four times as common in diabetic adolescents as in their nondiabetic peers (p < .001). Strict diet restriction and insulin misuse (p < .01) were related to DEBs. Disordered eating behaviors make a significant contribution to menstrual problems (p < .001) and poor metabolic control (p < .001). There was a nonsignificant negative correlation between DEBs and the BIS score. Health care professionals should be aware of the potential effect of subclinical and clinical DEBs including insulin misuse and strict diet in weight-conscious people with Type 1 diabetes who have poor metabolic control and menstrual problems.

Personality factors and disordered eating in young women with type 1 diabetes mellitus

The authors examined the association between the presence of personality variables implicated in the pathogenesis of eating disorders and the presence of eating disorder symptoms in 51 women with type 1 diabetes. Subjects were assessed with interview instruments and self-report questionnaires, including scales measuring eating disorder symptoms, borderline personality characteristics, and perfectionism. Fourteen subjects displayed moderate to severe eating disorder symptoms. Perfectionism was related to attitudinal aspects of eating disorders (e.g., weight preoccupation), and borderline personality characteristics were related to disordered behaviors (e.g., insulin omission) and poor glycemic control. The results suggest that personality factors are related to disordered eating and poor glycemic control in diabetic women.

Eating disorders in patients with type 1 diabetes: a meta-analysis

A meta-analysis of controlled studies on prevalence of eating disorders in Type 1 diabetes was performed in order to assess differences between diabetic and non-diabetic female subjects. All controlled studies using the Diagnostic and Statistical Manual of Mental Disorders Third Edition Revised (DSM Ill-R) or the DSM Fourth Edition (DSM IV) criteria for interview-based diagnosis were included in the analysis. The total sample was composed of 748 and 1587 female subjects with and without diabetes, respectively. The prevalence of anorexia nervosa (AN) in Type 1 diabetic subjects was not significantly different from that of controls (0.27 vs 0.06%), while that of bulimia nervosa and of the two conditions combined was significantly higher in diabetic patients (1.73 vs 0.69%, and 2.00 vs 0.75%, respectively; both p < 0.05). Type 1 diabetes is associated with a higher prevalence of bulimia nervosa in females.

Prevalence and clinical manifestations of eating disorders in Austrian adolescents with type-1 diabetes

OBJECTIVES

To investigate prevalence and clinical manifestations of DSM-IV clinical eating disorders and subsyndromal eating problems among adolescents with type-1 diabetes.

METHOD

A clinical sample of 251 adolescents with type-1 diabetes was recruited from multiple centres. Of these adolescents, 199 (96 girls and 103 boys--79.3% participation rate) with a mean age of 14.1 years (SD: 2.6) were screened for eating disorders and then underwent DSM-IV-based clinical assessment of eating disorders by interview.

RESULTS

11.5% of the girls and none of the boys with type-1 diabetes had DSM-IV eating disorders, whereas 13.5% of the girls and 1% of the boys had subsyndromal problems of eating and shape. Girls with both type-1 diabetes and a clinical or subclinical eating disorder had a significantly higher body-mass index than those without eating problems.

CONCLUSION

This Austrian study supports cumulative international evidence that among youths with type-1 diabetes, adolescent girls and especially those having a higher body mass are particularly vulnerable for manifesting pathology of eating, weight and shape. Thus, this particular population requires screening of eating behaviour and relevant psychopathology, close monitoring, and psychosocial interventions through cooperative efforts of specialised centres.