Doubly disabled: diabetes in combination with an eating disorder

Support Provided by Caregivers for Community-Dwelling Diabetic Hispanic Adults with Intellectual Disabilities and Comorbid Conditions

Diabetes is an age-related chronic health condition and a major public health concern. Diabetes is one of the significant causes of morbidity and mortality and a major contributing factor to dementia. Recent research reveals that Hispanic Americans are at an increased risk of chronic conditions such as diabetes, dementia, and obesity. Recent research also revealed that diabetes develops at least ten years earlier in Hispanics and Latinos than in neighboring non-Hispanic whites. Furthermore, the management of diabetes and providing necessary/timely support is a challenging task for healthcare professionals. Caregiver support is an emerging area of research for people with diabetes, mainly family caregiver support work for Hispanic and Native Americans. Our article discusses several aspects of diabetes, factors associated with diabetes among Hispanics, its management, and how caregivers can support individuals with diabetes.

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.

Global trends in diabetes complications: a review of current evidence

In recent decades, large increases in diabetes prevalence have been demonstrated in virtually all regions of the world. The increase in the number of people with diabetes or with a longer duration of diabetes is likely to alter the disease profile in many populations around the globe, particularly due to a higher incidence of diabetes-specific complications, such as kidney failure and peripheral arterial disease. The epidemiology of other conditions frequently associated with diabetes, including infections and cardiovascular disease, may also change, with direct effects on quality of life, demands on health services and economic costs. The current understanding of the international burden of and variation in diabetes-related complications is poor. The available data suggest that rates of myocardial infarction, stroke and amputation are decreasing among people with diabetes, in parallel with declining mortality. However, these data predominantly come from studies in only a few high-income countries. Trends in other complications of diabetes, such as end-stage renal disease, retinopathy and cancer, are less well explored. In this review, we synthesise data from population-based studies on trends in diabetes complications, with the objectives of: (1) characterising recent and long-term trends in diabetes-related complications; (2) describing regional variation in the excess risk of complications, where possible; and (3) identifying and prioritising gaps for future surveillance and study.

Prevalence of psychiatric disorders in patients with diabetes types 1 and 2

BACKGROUND

Diabetes mellitus, classified into types 1 and 2, is a chronic disease that shows high comorbidity with psychiatric disorders. Insulin-dependent patients show a higher prevalence of psychiatric disorders than do patients with type 2 diabetes.

METHODS

This research involved the participation of 200 subjects divided into 2 groups: 100 patients with diabetes type 1 and 100 patients with diabetes type 2. This study used the Mini International Neuropsychiatric Interview for the identification of psychiatric disorders.

RESULTS

Of the 200 participants, 85 (42.5%) were found to have at least 1 psychiatric disorder. The most prevalent disorders were generalized anxiety disorder (21%), dysthymia (15%), social phobia (7%), current depression (5.5%), lifelong depression (3.5%), panic disorder (2.5%), and risk of suicide (2%). Other disorders with lower prevalence were also identified. The groups showed a statistically significant difference in the presence of dysthymia, current depression, and panic disorder, which were more prevalent in patients with diabetes type 1.

CONCLUSION

The high prevalence of psychiatric disorders in diabetic patients points to the need for greater investment in appropriate diagnostic evaluation of patients that considers mental issues. The difference identified between the groups shows that preventive measures and therapeutic projects should consider the specific demands of each type of diabetes.

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.

Disordered eating behaviors in type 1 diabetic patients

Patients with type 1 diabetes mellitus are at high risk for disordered eating behaviors (DEB). Due to the fact that type 1 diabetes mellitus is one of the most common chronic illnesses of childhood and adolescence, the coexistence of eating disorders (ED) and diabetes often affects adolescents and young adults. Since weight management during this state of development can be especially difficult for those with type 1 diabetes, some diabetics may restrict or omit insulin, a condition known as diabulimia, as a form of weight control. It has been clearly shown that ED in type 1 diabetics are associated with impaired metabolic control, more frequent episodes of ketoacidosis and an earlier than expected onset of diabetes-related microvascular complications, particularly retinopathy. The management of these conditions requires a multidisciplinary team formed by an endocrinologist/diabetologist, a nurse educator, a nutritionist, a psychologist and, frequently, a psychiatrist. The treatment of type 1 diabetes patients with DEB and ED should have the following components: diabetes treatment, nutritional management and psychological therapy. A high index of suspicion of the presence of an eating disturbance, particularly among those patients with persistent poor metabolic control, repeated episodes of ketoacidosis and/or weight and shape concerns are recommended in the initial stage of diabetes treatment, especially in young women. 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.

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.

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.

Eating disorders and type 1 diabetes mellitus in adolescence

One of the main difficulties in managing type 1 diabetes mellitus (T1DM) in the young is nutritional treatment. Studies have shown that adolescents (particularly adolescent girls and young women) have an increased risk for clinical and sub-clinical eating disorders. Adjustment to the nutritional regimen and, consequently, to the management of the disease in adolescence seems to involve a complex interplay of various psychosocial and biological aspects. The aim of this review is to consider the relationship between T1DM and eating disorders in adolescence in the light of some important biological psychological and familial factors. Further research is required in order to detect the degree of the interactions between these factors in adolescents with T1DM.

Diabetes e transtornos alimentares: uma associação de alto risco

O diabetes mellitus (DM) é uma doença crônica que cursa com várias complicações clínicas e está entre as maiores causas de morbidade e mortalidade no Brasil. A presença de comorbidades psiquiátricas, principalmente depressão e transtornos alimentares (TA), no paciente diabético, pode interferir no controle metabólico e aumentar as complicações da doença. Entre os vários fatores na associação entre o DM e os TA, aspectos psicológicos relacionados ao DM, assim como restrições dietéticas, desempenham função importante na expressão de comportamentos alimentares inadequados nesta população. O objetivo do presente artigo é apresentar uma atualização sobre a associação entre o DM e os TA. Serão descritos dados sobre a epidemiologia, fatores de risco, aspectos clínicos, evolução e tratamento da comorbidade entre os TA (anorexia nervosa, bulimia nervosa e transtorno da compulsão alimentar periódica) e DM tipos 1 e 2. O diagnóstico precoce e o tratamento adequado de um TA associado parece se correlacionar a um melhor prognóstico do DM.

Eating disorders in young women with type 1 diabetes mellitus

Research findings from the past decade regarding the association of type 1 diabetes mellitus and eating disorders are critically reviewed in this paper. Although there has been much debate regarding the specificity of this association, a recent large multisite case-controlled study demonstrated that the prevalence rates of both full syndrome and subthreshold eating disorders among adolescent and young adult women with diabetes are twice as high as in their nondiabetic peers. Further, a 4-year follow-up study showed that disordered eating behavior in young women with diabetes often persists and is associated with a threefold increase in the risk of diabetic retinopathy. These eating disturbances tend to be associated with impaired family functioning and with poor diabetes management. Health care professionals should maintain a high index of suspicion for the presence of an eating disturbance among young women with diabetes, particularly among those with persistently poor metabolic control and/or weight and shape concerns. Screening for such disturbances should begin during the prepubertal period among girls with diabetes. A brief psychoeducational intervention leads to a reduction in disturbed eating attitudes and behavior but is not sufficient to improve metabolic control. More intensive treatment approaches, which should include a family-based component, may be needed to improve metabolic control. The evaluation of these and other treatment approaches is indicated in view of the serious short- and long-term health risks associated with eating disorders in young women with diabetes.

Disordered eating, body mass, and glycemic control in adolescents with type 1 diabetes

OBJECTIVE

To examine the relationship between disordered eating attitudes and behaviors, BMI, and glycemic control in adolescents with type 1 diabetes.

RESEARCH DESIGN AND METHODS

In a cross-sectional design, 152 adolescents (ages 11-19 years) completed three scales from the Eating Disorders Inventory (EDI): Body Dissatisfaction, Drive for Thinness, and Bulimia. All subjects had diabetes for > 1 year. Glycemic control was assessed by glycosylated hemoglobin (HbA1c). Height and weight were measured to assess BMI.

RESULTS

Adolescents with type 1 diabetes did not report more disordered eating attitudes and behaviors than the normative comparison sample. Male subjects with type 1 diabetes reported fewer symptoms of bulimia and female subjects with type 1 diabetes reported greater body satisfaction than the normative group. A higher BMI was a significant predictor of greater body dissatisfaction, more so for female than male subjects. Symptoms of bulimia were associated with older adolescence and female sex. Those with more symptoms of bulimia were also more likely to have a higher BMI. Sex (female) and body dissatisfaction (more dissatisfied) predicted a stronger desire to be thin. Longer duration of disease, more symptoms of bulimia, and obesity all predicted poorer glycemic control.

CONCLUSIONS

Female patients aged 13-14 years seem to be at greatest risk for developing disordered eating patterns. Using the clinical cutoff score (> or = 5) of the EDI Bulimia subscale as a screener in diabetes clinics may help identify adolescents whose disordered eating patterns are likely to compromise their glycemic control.

Diabetes mellitus and eating disorders: a multicenter study on the comorbidity of the two diseases

Because diet is a key issue in the treatment of diabetes mellitus, it is assumed that these patients are prone to eating disorders. In a multicenter study, we have therefore assessed the prevalence of eating disorders in 662 patients with insulin dependent diabetes mellitus (IDDM) (n = 340) and non-insulin-dependent diabetes mellitus (NIDDM) (n = 322). A two-stage study combining self-rating questionnaires and a standardized interview was carried out. We found a prevalence of eating disorders of 5.9% (lifetime prevalence of 10%), irrespective of gender and type of diabetes; 4.1% of the whole sample reported intentional insulin undertreatment or omission. When patients were stratified according to IDDM and NIDDM, there was no difference in the prevalence of all eating disorders (point prevalence 5.5% vs. 6.5%, lifetime prevalence 10.0% vs. 9.9%). Prevalence of bulimia nervosa (BN) was more frequent in IDDM patients (point prevalence 1.5% vs. 0.3%, lifetime prevalence 3.2% vs. 1.9%) and binge eating (BED) was more frequent in NIDDM patients (point prevalence 1.8% vs. 3.7%, lifetime prevalence 2.6% vs. 5.9%). We conclude that eating disorders seem to be equally frequent in IDDM and NIDDM patients. However, there might be different features of eating disorders in both types of diabetes.

Disordered eating behavior and microvascular complications in young women with insulin-dependent diabetes mellitus

BACKGROUND

Insulin-dependent diabetes mellitus (IDDM) and eating disorders are relatively common among young women in North America. Their coexistence could lead to poor metabolic control and an increased risk of the microvascular complications of IDDM.

METHODS

We studied 91 young women with IDDM at base line and four to five years later to determine the prevalence and persistence of disordered eating behavior (on the basis of self-reported eating and weight-loss practices, including the intentional omission or underdosing of insulin to control weight) and the association of such eating disorders with metabolic control, diabetic retinopathy, and urinary albumin excretion. At base line, the mean age of the young women was 15+/-2 years and the duration of diabetes was 7+/-4 years.

RESULTS

At base line, 26 of 91 young women (29 percent) had highly or moderately disordered eating behavior, which persisted in 16 (18 percent) and improved in 10 (11 percent). Of the 65 women with normal eating behavior at base line (71 percent), 14 (15 percent) had disordered eating at follow-up. Omission or underdosing of insulin lose weight was reported by 12 of 88 young women (14 percent) at base line and 30 (34 percent) at follow-up (P=0.003). At base line, the mean (+/-SD) hemoglobin A(1c) value was higher in the group with highly disordered eating behavior (11.1+/-1.2 percent) than in the groups whose eating behavior was moderately disordered (8.9+/-1.7 percent) or nondisordered (8.7+/-1.6 percent, P<0.001). Disordered eating at base line was associated with retinopathy four years later (P=0.004), when 86 percent of the young women with highly disordered eating behavior, 43 percent of those with moderately disordered eating behavior, and 24 percent of those with nondisordered eating behavior had retinopathy.

CONCLUSIONS

Disordered eating behavior is common and persistent in young women with IDDM and is associated with impaired metabolic control and a higher risk of diabetic retinopathy.