04/20/2024
Eating Disorders and Diabetes
Early interview-based prevalence studies on the topic of eating disorders among young women failed to find differences in the prevalence of eating disorders among young women with and without diabetes (Fairburn, Peveler, Davies, Mann, & Mayou, 1991; Peveler, Fairburn, Boller, & Dunger, 1992; Striegel- Moore, Nicholson, & Tamborine, 1992). However, the above studies have been criticized for their small sample sizes and their focus on young women in the age group at the highest risk for eating disorders, thus handicapping their statistical power and their generalizability (Jones et al., 2000). In a more recent study utilizing a much larger sample size, it was determined that females aged twelve to nineteen with diabetes were two and half times more likely to have an eating disorder than their counterparts without diabetes, with 10% of the females with diabetes meeting DSM-IV criteria for an eating disorder diagnosis and only 4% of those without diabetes meeting DSM criteria (Jones et al., 2000). The teens with diabetes were also almost twice as likely to have a sub-threshold eating disorder as their counterparts without diabetes (Jones et al., 2000). In a recent study of 678 youth with type 2 diabetes, 26% reported binge eating, with significant relationships between binge eating patterns, higher levels of obesity, psychosocial distress, and poorer quality of life (The TODAY Study Group, 2011).
Despite the differences in reported prevalence rates of eating disorders, full-blown or sub-threshold, mental health providers should be aware that eating disorders can be perilous for people with diabetes and they may represent a very important issue for a particular sub-group of people with diabetes: young women and adolescent females (Colton, Olmstead, Daneman, Rydall, & Rodin, 2007; Daneman, 2002; Jones, Lawson, Daneman, Olmstead, & Rodin, 2000; Smith, Latchford, Hall, & Dickson, 2008). Moreover, research has demonstrated that disordered eating behavior in young women with diabetes is often highly persistent, warranting intensive clinical attention (Roberts, 2007; Rodin, Olmstead, Rydall, Maharaj, Colton, Jones, Biancucci, & Danemen, 2002; Smith et al., 2008).
There have been several theories as to why female adolescents and young women with diabetes are at elevated risk for eating disorders and/or sub-threshold eating disorders. One theory posits that at the onset and during the initial course of the disease, many adolescents and young women will experience a cycle of weight loss and subsequent weight gain with the initiation of insulin treatment and a trend toward a higher body mass index (Diabetes Control and Complications Trial Research Group, 1988). Psychological discomfort with increased weight and shifts in body image at a particularly vulnerable time developmentally may catalyze the developing of an eating disorder. Another theory proposes that the dietary restraint involved in diabetes management may impair proper eating habits, making eating-disordered behavior more likely. One particularly dangerous weight management strategy commonly utilized by individuals with diabetes and co-morbid eating disorders (or sub-threshold eating disorders) that the clinician should be aware of is the deliberate under-dosing or complete omission of insulin altogether (Ackard, Vik, Neumark-Sztainer, Schmitz, Hannan, & Jacobs, 2008; Jones et al., 2000; Rodin & Daneman, 1992). It is estimated that 11% of adolescent females and young women with diabetes are currently taking less than their prescribed dose of insulin to lose weight (Jones et al., 2000). Given these research findings regarding eating disorders, mental health providers must take the time to conduct a thorough eating disorders assessment with all adolescent females and young women, particularly those known to have difficulty regulating their blood glucose.
Medical Consequences of Co-Morbid Eating Disorders
The presence of an eating disorder or sub-clinical disordered eating pattern has been linked to poorer blood glucose control, higher HbA1c levels, increased triglyceride levels, and an overall increased risk of long-term medical complications (Pinhas-Hamiel, Levy-Shraga, 2013; Allison, Crow, Reeves, West, Foreyt, Dilillo, Wadden, Jeffery, Van Dorsten, & Stunkard, 2007; Affenito, Lammi- Keefe, Vogel, Backstrand, Welsch, & Adams, 1997; Daneman, 2002; Rydall, Rodin, Olmsted, Devenyi, & Daneman, 1997; Smith et al., 2008). One medical complication that is especially common among women with diabetes and a co-morbid eating disorder is retinopathy. One study found that as many as 86% of women identified as having diabetes and an eating disorder would also develop retinopathy within four years (Rydell, et al., 1997). In comparison, the rate of developing retinopathy in diabetic women who do not suffer from an eating disorder was 24%. This percentage difference suggests that eating disorders in young women are associated with a threefold increase in the risk of diabetic retinopathy. Clinicians should be mindful that eating disturbances are often associated with impaired family functioning which, in turn, can negatively impact an adolescent or young adult’s ability to manage diabetes (Rodin et al., 2002). Adjunct family therapy is highly recommended in the psychological treatment of anyone with diabetes and co-morbid eating disorder conditions or symptom constellations.
Marty Lerner, Ph.D.
Board Certified and Licensed Clinical Psychologist
Florida Licensure PY2389
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