Disordered Eating Behavior in Individuals With Diabetes

This review was conducted to examine disordered eating behavior (DEB), including diagnosable eating disorders, in the context of diabetes. The use of criteria and assessment methods standardized on the healthy population is examined. Also considered is the need for modified assessment methods and classification of this behavior when evaluating patients with diabetes. Future directions for research are suggested. Literature published from 1980 to present was examined using “eating disorders and diabetes” as search terms. Over 100 peer-reviewed articles were identified via PubMed, Cochrane Reviews, PsycInfo, etc. Bibliographies from articles were reviewed to ascertain additional publications. Cited articles include reviews and individual studies indicating experimental design (self as control, healthy control, or population estimate), assessment methods (self-report, questionnaires, and structured/clinical interviews), and use of standard diagnostic criteria. Not all relevant articles could be included. However, some older references (published before 2000) are included because they provide foundation literature from which our understanding of DEB in the population of patients with diabetes derives and/or are validation studies for measurement methods. Additional references pertinent to hypothesized mechanisms are cited. Most studies, including those in a 2005 meta-analysis (N 8 casecontrolled studies), tend to focus on young women with type 1 diabetes, usually between ages 15–35 years, when weight concerns, DEB, and eating disorders are at a high prevalence (1). Recent studies have included type 2 diabetic patients, minorities, and male patients (2– 9). The diagnosis of diabetes has been associated with elevated rates of DEB and eating disorders, particularly when insulin omission is considered purging (1,8–11). Diagnosed eating disorders and subclinical DEB have been associated with poorer health in individuals with type 1 diabetes. Early reports found prevalence rates of the co-occurrence of diabetes and DEB to be low and accompanied by psychiatric comorbidity and weight loss, but diabetes control was not compromised (12–14). More recent cross-sectional studies have demonstrated a positive association between elevated A1C and diagnosable eating disorders (2), subclinical DEB (8), and intentional insulin omission (1). The presence of diagnosable eating disorders and behavior categorized as subclinical DEB has been associated with increases in retinopathy (15), neuropathy (16), transient lipid abnormalities (17), hospitalizations for diabetic ketoacidosis (6), and poor short-term metabolic control (1,6,8,18). Studies assessing the association of DEB and eating disorders with long-term metabolic control have produced mixed results (6,19–22). A prospective 5-year study did not find a significant relationship between DEB or eating disorders and poorer glycemic control (22). Less is known about the relationships between DEB and health status in individuals with type 2 diabetes (4,7,9). PREVALENCE OF DIAGNOSABLE EATING DISORDERS AND DEB IN PATIENTS WITH DIABETES— Controversyexists regarding whether there is increased prevalence of diagnosable eating disorders and DEB in individuals with type 1 diabetes than referent populations (1,8,19). Rates similar to (1,8,23–25) and higher than (1,6,23,24,26) healthy sameaged peers (19,27) have been found. Some studies found equivalent or lower rates of diagnosable eating disorders but higher rates of DEB, particularly bulimia symptoms. Estimates of diagnosable eating disorders and DEB in adolescent and young adult females with type 1 diabetes range from 3.8% (12)–27.5% for patients classified as bulimic or having binge eating disorder (BED), based upon evaluation with the Eating Disorders Examination (EDE), (28) and 38–40%when insulin omission is considered purging (21,29). Individuals on insulin therapy may find insulin omission or dose reduction an easy method for weight management via glycosuria. This method is frequently reported by adolescent and young adult females with type 1 diabetes (2,29,30). Rates of both subclinical DEB and diagnosable eating disorders are variable based on the criteria used. When establishing the relative prevalence of DEB in the diabetic population, most studies have not matched control samples for weight (1,19,21,26). Weight status is a strong predictor of eating disorders and DEB among overweight women attempting weight loss (31). Type 1 diabetic cohorts studied have been significantly heavier than comparison groups, with the average BMI above the normal range (1,19). To compare an ageand sex(but not BMI-) matched control sample to one with type 1 diabetic patients, the EDE (32) was administered. Similar rates of eating pathology were identified. However, using the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV) criteria, which include insulin omission (33), higher rates were identified in the diabetic sam● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●