Eating Disorders and IDDM: A problematic association

DIABETES CARE Eating Disorders and IPPM GARY M. RODIN DENIS DANEMAN MB IDDM and eating disorders are common conditions in young women. Whether a specific association exists between these two disorders remains controversial. Some studies have suggested an increased incidence of eating disorders in young women with IDDM, whereas others have not detected such an increase. These differences may be attributable, at least in part, to methodological issues in study design, measurement tools, and relatively small sample sizes. Whether the prevalence of eating disorders in IDDM is increased will be resolved only by larger studies that use standardized diagnostic interviews. We suspect that certain aspects of IDDM and its management may trigger the expression of an eating disorder in susceptible individuals. Required dietary restraint and weight gain related to diabetes management are the factors most likely to be implicated. Eating disorders are relatively common in young women with IDDM and may contribute to impaired metabolic control with hypoglycemia and DKA, and to long-term microvascular complications of diabetes. Omission or reduction of required insulin, an extremely common means of weight control in these young women, is likely an important factor in this regard. Further research is required to determine more precisely the relationship between IDDM and eating disorders, and the effects of eating disorders on metabolic control and chronic complications of IDDM. - tured interviews (6), lifetime diagnoses of anorexia nervosa and bulimia based on DSM-III criteria were made in 0.5 and 4.2%, respectively, of high-school students aged 14-17 yr. A review of the epidemiology of bulimia nervosa suggests that the prevalence of this disorder in adolescent and young adult women is ~ 1 % , based on the stricter DSM-I1I-R criteria (7). The DSM-III (8) and DSMIII-R (9) criteria for anorexia nervosa, bulimia, and bulimia nervosa are illusTable 1Summary of diagnostic criteria for anorexia nervosa WEIGHT LOSS OF 2 5 % OF ORIGINAL BODY WEIGHT AND/OR OF PROJECTED WEIGHT GAIN IN INDIVIDUALS < 1 8 YR. REFUSAL TO MAINTAIN BODY WEIGHT OVER A MINIMAL NORMAL LEVEL FOR AGE AND HEIGHT. DISTURBANCE OF BODY IMAGE, (E.G., "FEELS FAT" EVEN WHEN EMACIATED). INTENSE FEAR OF BECOMING OBESE, WHICH DOES NOT DIMINISH AS WEIGHT LOSS PROGRESSES, N O KNOWN PHYSICAL ILLNESS TO ACCOUNT FOR WEIGHT LOSS. WEIGHT LOSS AND MAINTENANCE OF BODY WEIGHT 15% BELOW THAT EXPECTED FOR AGE AND HEIGHT. DISTURBANCE IN THE WAY IN WHICH ONE'S BODY WEIGHT, SIZE, OR SHAPE IS EXPERIENCED, (E.G., "FEELS FAT" EVEN WHEN EMACIATED). INTENSE FEAR OF GAINING WEIGHT OR BECOMING FAT, EVEN THOUGH UNDERWEIGHT. ABSENCE OF > 3 MENSES WHEN OTHERWISE EXPECTED TO OCCUR. SURVEYS OF PATIENTS WITH EATING DISORDERS One strat In this paper, we focus on the egy to assess the association of IDDM systematic studies that have sought to with eating disorders is to survey the define the association between IDDM prevalence of IDDM in patients with eatand eating disorders, the short- and ing disorders. Nielsen et al. (11) retrolong-term metabolic and psychological spectively reviewed 242 consecutive Table 2Summary of diagnostic criteria for bulimia (DSM-III) and bulimia nervosa (DSM-III-R) BULIMIA NERVOSA (DSM-III-R) RECURRENT EPISODES OF BINGE-EATING (RAPID CONSUMPTION OF A LARGE AMOUNT OF FOOD IN A DISCRETE TIME PERIOD, USUALLY < 2 H ) . AT LEAST THREE OF THE FOLLOWING: CONSUMPTION OF HIGH CALORIC, EASILY INGESTED FOOD DURING A BINGE. INCONSPICUOUS EATING DURING A BINGE. TERMINATION OF BINGES BY ABDOMINAL PAIN, SLEEP, SOCIAL INTERRUPTION, OR SELF-INDUCED VOMITING. REPEATED ATTEMPTS TO LOSE WEIGHT BY RESTRICTIVE DIETING, SELF-INDUCED VOMITING, OR USE OF CATHARTICS OR DIURETICS. FREQUENT WEIGHT FLUCTUATIONS > 10 LBS CAUSED BY ALTERNATING BINGES AND FASTS. AWARENESS THAT THE EATING PATTERN IS ABNORMAL AND FEAR OF NOT BEING ABLE TO STOP EATING VOLUNTARILY. DEPRESSED MOOD AND SELF-DEPRECATING THOUGHTS AFTER EATING BINGES. BULIMIC EPISODES ARE NOT CAUSED BY ANOREXIA NERVOSA OR ANY KNOWN PHYSICAL DISORDER. RECURRENT EPISODES OF BINGE-EATING (RAPID CONSUMPTION OF A LARGE AMOUNT OF FOOD IN A DISCRETE PERIOD OF TIME), A FEELING OF LACK OF CONTROL OVER EATING BEHAVIOR DURING THE EATING BINGES. REGULAR SELF-INDUCED VOMITING, USE OF LAXATIVES OR DIURETICS, STRICT DIETING OR FASTING, OR VIGOROUS EXERCISE TO PREVENT WEIGHT GAIN. > 2 B1NGES/WK FOR > 3 MO. PERSISTENT OVERCONCERN WITH BODY SHAPE AND WEIGHT. cases of eating disorders that had been treated between 1960 and 1984 at the Psychiatric and Child Psychiatric Clinics at Rigshospitalet (Copenhagen, Denmark). They found that IDDM was present in 5 cases (.02%), all female. Four of these patients were diagnosed with anorexia nervosa and one with bulimia, based on DSM-III criteria. Growth failure was evident in two of these patients. The authors considered that the prevalence of eating disorders in this sample was six times what might be expected on a chance basis, although the sample studied may not have been representative of patients with eating disorders in that community. SURVEYS OF PATIENTS WITH IDDM A more common research approach has been to assess eating and weight psychopathology in patients with IDDM. As described below, these include surveys of psychological disturbances and of diagnosable eating disorders. Self-reported psychological disturbances in IDDM patients compared with control subjects Some researchers have compared psychological disturbances not necessarily associated with diagnosed eating disorders in patients with IDDM versus control subjects. Although some studies (12) suggest that self-esteem is not more impaired and depressive symptoms are not more common in adolescent girls with IDDM, other research suggests that subtle disturbances may be present. For example, Hauser et al. (13) found that ego development and self-image complexity are impaired in adolescents with IDDM compared with similar nondiabetic individuals. These differences may not be specific to diabetes, as similar difficulties may be found in children with other medical illnesses (14). Findings with regard to eating and weight psychopathology in individuals with IDDM also have been conflicting. Using the EAT-26 and the BES, Wing et al. (15) studied 101 IDDM girls and 101 IDDM boys aged 12-18 yr. The EAT-26 (16) is a 26-item abbreviated version derived from factor analysis of the original 40-item EAT-40 scale (17). It consists of three factors or subscales that measure eating attitudes and habits related to dieting, bulimia and food preoccupation, and oral control. It is an objective, reliable, and well-validated self-report measure of eating disorder symptoms (16,17). Wing et al. (15) compared EAT-26 scores in the IDDM patients with those of 65 nondiabetic girls and 77 nondiabetic boys who were studied separately by Hsu et al. (18). Although it is not clear to what extent the control group is co (...truncated)