Disturbed Eating Behavior and Eating Disorders in Preteen and Early Teenage Girls With Type 1 Diabetes: A case-controlled study

PATRICIA COLTON MSC 1 MARION OLMSTED PHD 1 DENIS DANEMAN MB FRCPC 0 ANNE RYDALL MSC 1 GARY RODIN FRCPC 1 0 Department of Paediatrics, University of Toronto , Toronto, Ontario , Canada. General Hospital, University Health Network , 200 Elizabeth St., Toronto, ON, M5G 2C4 , Canada 1 Department of Psychiatry, University of Toronto , Toronto, Ontario , Canada; and the E p i d e m i o l o g y / H e a l t h S e r v i c e s / P s y c h o s o c i a l R e s e a r c h OBJECTIVE - To compare the prevalence of eating disturbances in preteen and early teenage girls with type 1 diabetes to their nondiabetic peers. RESEARCH DESIGN AND METHODS - A cross-sectional, case-controlled study of 101 girls with type 1 diabetes, ages 9 -14 years, and 303 age-matched, female nondiabetic control subjects was conducted. Participants completed a Children's Eating Disorder Examination interview. Socioeconomic status, BMI, and diabetes-related variables were assessed. Groups were compared using 2 analyses. RESULTS - Binge eating; the use of intense, excessive exercise for weight control; the combination of two disturbed eating-related behaviors; and subthreshold eating disorders were all more common in girls with type 1 diabetes. Metabolic control was not related to eating behavior in this study population. CONCLUSIONS - Eating disturbances, though mostly mild, were significantly more common in preteen and early teenage girls with type 1 diabetes. Screening and prevention programs for this high-risk group should begin in the preteen years. - E nervosa and bulimia nervosa and ating disorders, including anorexia their milder variants (eating disorder not otherwise specified [ED-NOS] and subthreshold disorders), are a group of psychiatric disorders unified by highly disturbed eating behavior and a constellation of psychological traits and symptoms. The eating behaviors can include fasting and dieting; binge eating; selfinduced vomiting; the abuse of laxatives, diet pills, diuretics, and other medications; and the use of intense, excessive exercise for weight control. The psychological traits and symptoms include preoccupation with body weight and shape, distortions of body image, and severely disturbed attitudes toward food, calories, and eating (1). Eating disorders have high medical and psychiatric comorbidity and the highest mortality rate of the psychiatric disorders, mostly by suicide (2 4). The etiology of eating disorders appears to be complex and multifactorial, involving individual, familial, and environmental vulnerability factors (5). Living with type 1 diabetes may be one such risk factor, although the nature and specificity of this association has been debated since the first published reports of eating disorders among diabetic individuals in the 1970s (6). Most published studies have found an absolute, if not always statistically significant, increase in the risk of eating disorders among female patients with type 1 diabetes compared with their nondiabetic peers. Nielsens 2002 metaanalysis of the work to date (7) concluded that bulimia nervosa, ED-NOS, and subthreshold eating disorders are all more common in female patients with type 1 diabetes. Disturbed eating behavior is very common among teenage girls and young women with type 1 diabetes, with binge eating reported by 45 80% and deliberate induction of glycosuria by reducing the insulin dosage or omitting insulin to promote weight loss reported by 12 40% (8 10). Eating disorders and milder disturbed eating behaviors are associated with many negative medical outcomes, including poor metabolic control, increased frequency of diabetes-related hospitalizations, and higher rates of diabetes-related complications, particularly retinopathy and perhaps neuropathy (1113). Several mechanisms have been proposed to explain the association between disturbed eating behavior and type 1 diabetes. These include the developmental effects of a chronic medical condition on body image and self-concept, the dietary focus and restraint imposed by a diabetes meal plan, and the higher BMI associated with insulin use (14,15). Beginning during the pubertal years, girls with type 1 diabetes are on average heavier than their nondiabetic peers (16 18). Increased BMI may be due to insulin use (19) and dietary dysregulation, in particular overeating and binge eating, which are common among older girls with type 1 diabetes. In vulnerable individuals, weight gain may promote a cycle of dieting, binge eating, and compensatory purging behavior, especially insulin omission, which is easily implemented and highly effective in promoting rapid weight loss. The preteen and early teenage years are a period of rapid physical and psychological growth and development, as girls adjust to the physical changes of puberty, with its profound personal and social meaning. Body dissatisfaction, dieting, and exercise to control weight are all common in girls in the general population at this stage (20 22), although binge eating and more extreme weight control measures such as self-induced vomiting and laxative abuse are rare. The nature and prevalence of disturbed eating behavior in preteen and early teenage girls with type 1 diabetes have not been established. To our knowledge, only two studies have considered girls age 11 years or younger with type 1 diabetes (23,24). Although one study (23) found no significant eating disorder symptoms in preteen girls, it included only 18 subjects in this age range. The study of Peveler et al. (24) included only five girls ages 11 and 12 years. The present study used a crosssectional, case-control design to compare the rates of disturbed eating behavior and eating disorders (a subset with more significant disturbed eating behavior) in preteen and early teenage girls with type 1 diabetes with those in a nondiabetic control group. We hypothesized that 1) disturbed eating behavior and eating disorders would be more common in preteen and early teenage girls with type 1 diabetes than in their nondiabetic peers, and 2) disturbed eating behavior would be associated with poorer metabolic control in diabetic girls. Determining the nature and prevalence of disturbed eating behavior and eating disorders in girls in this age range would help to clarify the age of optimal screening, prevention, and intervention in this high-risk group. RESEARCH DESIGN AND METHODS Girls with type 1 diabetes, ages 9 13 years, were recruited during their diabetes clinic appointments at the Hospital for Sick Children (HSC), Toronto, Canada. Girls who reached their 14th birthday after being recruited but before completing the assessment were included. This clinic provides comprehensive diabetes care to 70% of the children and teenagers with type 1 diabetes in the Toronto area. Only girls who received regular comprehensive care at HSC were recruited into the study. Control girls were recruited from grades 4 8 at eight parti (...truncated)