Eating Disorders in Girls and Women With Type 1 Diabetes: A Longitudinal Study of Prevalence, Onset, Remission, and Recurrence

CLIN CARE/EDUCATION/NUTRITION/PSYCHOSOCIAL 1212 Diabetes Care Volume 38, July 2015 Eating Disorders in Girls and Women With Type 1 Diabetes: A Longitudinal Study of Prevalence, Onset, Remission, and Recurrence Patricia A. Colton,1,2 Marion P. Olmsted,1,2 Denis Daneman,3,4 Jamie C. Farquhar,1 Harmonie Wong,1 Stephanie Muskat,1 and Gary M. Rodin1,2 Diabetes Care 2015;38:1212–1217 | DOI: 10.2337/dc14-2646 OBJECTIVE Girls and women with type 1 diabetes are at increased risk for developing eating disorders (EDs), and these disorders are associated with serious diabetes-related medical complications. This study describes the longitudinal course of disturbed eating behavior (DEB) and EDs in a cohort with type 1 diabetes. RESEARCH DESIGN AND METHODS A total of 126 girls with type 1 diabetes receiving care for diabetes at The Hospital for Sick Children in Toronto participated in a series of seven interview-based assessments of ED behavior and psychopathology over a 14-year period, beginning in late childhood. Survival analysis was used. RESULTS Mean age was 11.8 6 1.5 years at time 1 and 23.7 6 2.1 years at time 7. At time 7, 32.4% (23/71) met the criteria for a current ED, and an additional 8.5% (6/71) had a subthreshold ED. Mean age at ED onset (full syndrome or below the threshold) was 22.6 years (95% CI 21.6–23.5), and the cumulative probability of onset was 60% by age 25 years. The average time between onset of ED and subsequent ED remission was 4.3 years (95% CI 3.1–5.5), and the cumulative probability of remission was 79% by 6 years after onset. The average time between remission of ED and subsequent recurrence was 6.5 years (95% CI 4.4–8.6), and the cumulative probability of recurrence was 53% by 6 years after remission. CONCLUSIONS In this longitudinal study, EDs were common and persistent, and new onset of ED was documented well into adulthood. Further research regarding prevention and treatment for this vulnerable group is urgently needed. The prevalence, clinical characteristics, and medical consequences of disturbed eating behavior (DEB) and eating disorders (EDs) in individuals with type 1 diabetes has received increasing attention since case reports of this dangerous combination were first published in the 1980s (1,2). Although the specificity of this association was initially unclear, systematic research has demonstrated that teenage girls and women with type 1 diabetes are at significantly increased risk of DEB compared with their nondiabetic peers (3). Such DEB includes dieting, fasting, binge-eating, and a range of compensatory and purging behaviors that can directly interfere with optimal diabetes management. 1 Department of Psychiatry, University Health Network, Toronto, Canada 2 Department of Psychiatry, University of Toronto, Toronto, Canada 3 The Hospital for Sick Children, Toronto, Canada 4 Department of Paediatrics, University of Toronto, Toronto, Canada Corresponding author: Patricia A. Colton, patricia. . Received 7 November 2014 and accepted 8 March 2015. A slide set summarizing this article is available online. © 2015 by the American Diabetes Association. Readers may use this article as long as the work is properly cited, the use is educational and not for profit, and the work is not altered. care.diabetesjournals.org Deliberately underdosing or omitting insulin to induce hyperglycemia and loss of glucose in the urine, and thereby control weight, is a unique purging behavior to control weight that is available to individuals with type 1 diabetes (4). This is an important mediator of the association of DEB and EDs with poorer metabolic control (5,6) and contributes to an increased risk of a range of short-term and long-term diabetes-related medical complications. These include abnormal lipid profiles (7), diabetic ketoacidosis (6), retinopathy (8), neuropathy (9), and nephropathy (10), as well as higher than expected mortality (11). Several longitudinal studies of DEB and EDs in individuals with type 1 diabetes have been conducted. Pollock et al. (12) assessed eating problems in a group of 79 boys and girls, 8–13 years of age, at type 1 diabetes onset, over a period of up to 14 years. They found eating problems to be highly associated with psychiatric disorders and with pervasive noncompliance with medical treatment. Rydall et al. (8) found that DEB at the study baseline among a cohort of adolescent girls with type 1 diabetes predicted a tripled risk of retinopathy 4 years later. In a third study, Bryden et al. (13) assessed a group of individuals with type 1 diabetes in adolescence and then again in early adulthood. They found that rates of overweight, concern over weight and shape, and heightened dietary restraint all increased from adolescence to adulthood. DEB was common among the female participants, though it did not necessarily meet diagnostic thresholds for anorexia nervosa or bulimia nervosa, as did insulin underdosing for weight control. They found EDs or other significant eating problems in 26% of participants, as well as significant associations between eating problems, insulin misuse, and microvascular complications (14). Goebel-Fabbri et al. (15) assessed 234 adult women with type 1 diabetes twice over an 11-year period. They found insulin omission for weight control to be very common (reported by 30% at baseline). Insulin omission frequently persisted over the lengthy follow-up period and was associated with higher rates of diabetes-related medical complications and tripled risk of mortality. Finally, in earlier stages of the study (study baseline and 1- and 5-year followup [16–18]) described in this report, DEB Colton and Associates was usually mild but frequent and persistent among girls with type 1 diabetes during late childhood and adolescence. Earlier in the follow-up of this cohort, DEB was associated with higher BMI but not with poorer metabolic control. This report describes the prevalence, onset, remission, and recurrence of DEB and EDs in a cohort of girls with type 1 diabetes recruited in late childhood and followed into early adulthood. This 14-year, longitudinal study encompasses the peak age range of DEB and ED onset. It adds to the existing longitudinal literature in this high-risk group by using up to 7 assessments over the study period to calculate detailed estimates of the course of these disturbances during this crucial developmental period. RESEARCH DESIGN AND METHODS This study was reviewed and approved by the research ethics boards at The Hospital for Sick Children and University Health Network, Toronto, Canada. Participants were initially recruited from the Diabetes Clinic at The Hospital for Sick Children in Toronto during 1998 to 2001. All girls 9– 13 years of age with a type 1 diabetes duration .6 months at the study baseline (time 1) and fluency in English were invited to participate. Participants were assessed at time 1 (study baseline) as well as on six subsequent occasions. These occurred 1 (ti (...truncated)