Weight Control Practices and Disordered Eating Behaviors Among Adolescent Females and Males With Type 1 Diabetes

Dianne Neumark-Sztainer, PHD, Joan Patterson, PHD, Alison Mellin, PHD, Diann M. Ackard, PHD, Jennifer Utter, MPH, Mary Story, PHD and Joseph Sockalosky, MD

Disclosures

Diabetes Care. 2002;25(8) 

In This Article

Conclusions

Weight control practices were prevalent among the study population. Although the use of healthy weight control behaviors was most commonly reported, significant percentages of females (37%) and males (15%) reported the use of unhealthy or very unhealthy behaviors. Of particular concern was the misuse of insulin for weight regulation, reported by 7-10% of the females. While prevalences of unhealthy weight control behaviors reported in this study are of concern, they were lower than those found in a recent large population-based survey of adolescents in the greater St. Paul/Minneapolis area, using similar questions (with the exception of insulin misuse).[24] Prevalences were also considerably lower than those found in an earlier population-based study of Minnesota youth who reported having diabetes,[25] thus raising questions and concerns about the validity of making comparisons across studies, self-reported data on diabetes and on weight-control behaviors, and the representative nature of the study population in the current study.

Females who were more dissatisfied with their weight and who perceived themselves to be overweight were more likely to use unhealthy weight control behaviors. Among both genders, weight dissatisfaction was significantly correlated with disordered eating behaviors, as assessed with the DEPS; but associations between actual BMI and unhealthy weight control practices and disordered eating behaviors tended to be weak and inconsistent. Other studies have found positive associations between BMI and disordered eating among females with type 1 diabetes.[9,43] Together these findings suggest that special attention should be directed toward helping youth who are overweight, and particularly those who express body dissatisfaction, to find healthy ways to control their weight and to avoid unhealthy methods, especially insulin misuse.

The high prevalence of overweight among the study population is noteworthy in that 44% of the females and 40% of the males had BMI values at or above the 85th percentile. Similarly, Engstrom et al.[9] found that youth with type 1 diabetes were at increased risk for overweight. This raises challenges for health providers in helping adolescents with type 1 diabetes to engage in healthy weight control behaviors, yet avoid excessive weight preoccupation and the use of unhealthy weight control behaviors.

Associations between weight control and disordered eating behaviors and different aspects of the family environment were examined in order to gain insight into the types of family relationship patterns that might place youth at risk, or serve to protect them, from engaging in unhealthy behaviors. Fairly strong associations were found with family cohesiveness, indicating the importance of family support. This finding is consistent with results reported by others about the importance of good family relationships for optimal diabetes management.[11,18,35]

We did not find associations between the adolescents' weight control behaviors and the adolescents' perceptions of other aspects of the family environment, specifically family control or the encouragement of independence in individual family members. There was a tendency toward higher perceived family control by the females using the unhealthy weight control behaviors, and it could be that our sample was too small to detect significant differences on this variable. The two males who used very unhealthy weight control behaviors did report higher scores for family independence, but again the sample was too small to obtain statistical significance. One of the challenges of parenting an adolescent with type 1 diabetes is finding the right balance between encouraging youth responsibility for self-care and management of their diabetes as they mature into young adults, while simultaneously providing emotional support as they grapple with the meaning of having a chronic illness. These are important issues that need to be examined in more depth, perhaps using qualitative research methodologies.

Unhealthy weight control and other disordered eating behaviors were associated with poorer metabolic control, as evidenced by higher HbA1c levels. This is consistent with the findings of others.[8,13,32,41] The mean HbA1c levels of study participants were higher than the clinic goals for adolescents at the Diabetes Clinic, particularly among those who reported unhealthy and very unhealthy weight control practices. These findings suggest that even without a clinically significant eating disorder, the use of unhealthy weight control practices may have serious consequences for metabolic control among youth with type 1 diabetes.

This study had a number of strengths that increase the utility of the findings. The inclusion of males in the study population expands upon the current body of literature, as the majority of studies examining eating disorders/disordered eating among individuals with type 1 diabetes have included only females. The use of different measures of weight control practices/disordered eating and, in particular, the use of the DEPS,[2] which is specific to diabetes, enhances our ability to draw conclusions from the data. In a review of the literature on eating disorders and type 1 diabetes, Nielson and Molbak[26] stress the importance of using diabetes-specific tools, since the use of general measures is "likely to lead to the loss of information." Other strengths include the assessment of both measured BMI and weight perceptions, HbA1c values, and different aspects of the familial social environment using previously validated tools.[21]

A major study limitation was the relatively low response rate (58%), despite several attempts to reach the eligible clinic population. However, the attainment of data for BMI, age, and HbA1c levels for nonrespondents was helpful. The finding that nonrespondents had higher levels of HbA1c than respondents suggests that nonrespondents may have been more likely to engage in unhealthy weight control practices than respondents, but this cannot be stated with certainty. Thus, prevalence of data on unhealthy weight control behaviors among youth with type 1 diabetes should be interpreted cautiously. We would not expect associations (e.g., with family functioning or metabolic control) to be affected by the response rate. Furthermore, although the study population was diverse in terms of gender, age, and SES, its small size and its homogeneity in terms of family structure and race/ethnicity make it difficult to draw firm conclusions regarding the lack of sociodemographic differences in weight control/disordered eating behaviors. Finally, the cross-sectional study design limits our ability to discuss causality. Longitudinal studies are needed to assess whether low family cohesion leads to the use of unhealthy weight control practices. That said, it is noteworthy that family connectedness has been shown to be a key factor influencing a range of health-compromising behaviors in population-based samples of youth.[23,30,31]

Findings from the present study have implications for research and practice. The findings suggest a need for further research to explore the reasons that adolescents with type 1 diabetes engage in unhealthy weight control practices, despite the serious consequences of these behaviors. Of particular interest is the further exploration of familial factors in order to provide insight into helpful strategies for parenting an adolescent with type 1 diabetes. In addition, different types of treatment strategies should be evaluated in terms of their impact on weight-related behaviors. Our findings suggest that special attention should be directed toward females, youth with weight concerns, and youth from families with low levels of cohesiveness. A few screening questions regarding weight-related concerns and behaviors and regarding family relationships may be incorporated into clinic visits with adolescents. Some suggested introductory comments/questions include the following: "I would like to ask you a few questions about any weight-related concerns you may have. How concerned are you about your weight, let's say on a scale from 0 (not at all concerned) to 10 (extremely concerned)? Are you on a diet now to lose or maintain weight?" If there appear to be weight-related concerns, the following questions may be asked "Do you ever skip meals to lose or maintain weight? In the past year, have you ever tried to lose weight by vomiting, taking diet pills, using laxatives, skipping insulin, or modifying your insulin dose?" Responses to these questions should be addressed within the treatment plan. Treatment strategies need to take into account the unique needs of teenagers in their quest for independence from their parents, the desire of most teenagers to "fit in" with their peers, and strong social norms emphasizing thinness. Support activities for families, such as family counseling or group work with parents of adolescents with diabetes, may enhance family cohesiveness and lead to improved diabetes management and outcomes. Finally, health care providers working with adolescents with type 1 diabetes may need special training in identifying disordered eating behaviors, addressing the developmental needs of adolescent populations, and working with families to enhance communication and support.

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