By Baiyu Qi, MPH, PhD student UNC Department of Epidemiology

The co-occurrence of diabetes and eating disorders has been receiving considerable attention in the medical community (Coleman & Caswell, 2020). Individuals with type 1 diabetes (T1D) are at increased risk of developing an eating disorder, compared with individuals without T1D (Hastings et al., 2016; Jones et al., 2000). In female adolescents and young adults, the prevalence of DSM-IV eating disorders (10%) and subthreshold eating disorders (14%) in those with T1D is approximately twice as common as in their non-diabetic peers (4% and 8%, respectively; Jones et al., 2000). A defining behavioral feature of co-occurring eating disorders and T1D is missing insulin doses to influence shape and weight (Hastings et al., 2016; Jones et al., 2000).

Co-occurring eating disorders and T1D can be very damaging to general health, including increased physical complications from T1D compared with those who do not have any eating disorder. Additional complications include higher HbA1c levels (glycated hemoglobin—a measure to evaluate the long-term control of blood glucose concentrations) as a result of poor metabolic control, hyperglycemia (i.e., rising blood sugar) resulting from missed insulin doses, hypoglycemia (i.e., low blood sugar) resulting from not eating or not eating enough food, and diabetic ketoacidosis (i.e., production of excess blood acids by the body) caused by insulin reduction or omission (Jones et al., 2000; Hanlan et al., 2013; Chelvanayagam & James, 2018). Long-term complications include retinopathy (i.e., retinal disease resulting in impairment or loss of vision), neuropathy (i.e., nerve damage that primarily affects the hands, legs, and feet), and nephropathy (i.e., kidney disease) (Peveler et al., 2005; Chelvanayagam & James, 2018). If left untreated, co-occurring T1D and eating disorders can result in elevated morbidity and mortality. For example, a retrospective study showed that women with T1D who deviated from their insulin prescription had three times increased risk of death during the 11 years of follow-up, compared with those who reported maintaining their insulin regimen (Goebel-Fabbri et al., 2008).

Given the high prevalence and possible sequela of this co-occurring pattern, prevention and intervention strategies are needed. Screening for eating disorders or disordered eating should become a routine component of assessment and treatment for T1D. It is particularly helpful to use an eating disorder screening tool designed for patients with T1D, as standard eating disorder screening measures can over- or underestimate the prevalence of eating disorders in individuals with T1D (Doyle et al., 2017). In addition to screening, since T1D requires regular health care, all members of the treatment teams should be aware of and vigilant for signs of emerging disordered eating including unexplained weight loss or gain, unexplained shifts in T1D control, negative comments about  weight and shape, and negative attitudes toward the vigilance necessary to remain healthy while managing T1D. Including a behavioral medicine/psychology arm to the treatment team can assist with motivation, concerns about body shape and weight, and disordered eating or eating disorders (Hanlan et al., 2013). Lastly, for people who have both T1D and eating disorders, frequent communication between the diabetes and eating disorder treatment teams is essential for coordinated care. The need to closely monitor nutritional intake and blood sugar, which is essential for managing T1D, can often feel particularly challenging for people working toward recovery for eating disorders. Developing effective strategies for co-managing T1D and eating disorders can ensure both physical and psychological well-being.

References:

Chelvanayagam, S., & James, J. (2018). What is diabulimia and what are the implications for practice?. British Journal of Nursing, 27(17), 980-986.

Coleman, S. E., & Caswell, N. (2020). Diabetes and eating disorders: An exploration of ‘Diabulimia’. BMC Psychology, 8(1), 1-7.

Doyle, E. A., Quinn, S. M., Ambrosino, J. M., Weyman, K., Tamborlane, W. V., & Jastreboff, A. M. (2017). Disordered eating behaviors in emerging adults with type 1 diabetes: A common problem for both men and women. Journal of Pediatric Health Care, 31(3), 327-333.

Goebel-Fabbri, A. E., Fikkan, J., Franko, D. L., Pearson, K., Anderson, B. J., & Weinger, K. (2008). Insulin restriction and associated morbidity and mortality in women with type 1 diabetes. Diabetes Care, 31(3), 415-419.

Hanlan, M. E., Griffith, J., Patel, N., & Jaser, S. S. (2013). Eating disorders and disordered eating in type 1 diabetes: Prevalence, screening, and treatment options. Current Diabetes Reports, 13(6), 909-916.

Hastings, A., McNamara, N., Allan, J., & Marriott, M. (2016). The importance of social identities in the management of and recovery from ‘Diabulimia’: A qualitative exploration. Addictive Behaviors Reports, 4, 78-86.

Jones, J. M., Lawson, M. L., Daneman, D., Olmsted, M. P., & Rodin, G. (2000). Eating disorders in adolescent females with and without type 1 diabetes: Cross sectional study. Bmj, 320(7249), 1563-1566.

Peveler, R. C., Bryden, K. S., Neil, H. A. W., Fairburn, C. G., Mayou, R. A., Dunger, D. B., & Turner, H. M. (2005). The relationship of disordered eating habits and attitudes to clinical outcomes in young adult females with type 1 diabetes. Diabetes Care, 28(1), 84-88.