Disordered Eating Common in Youth with Type 1 Diabetes

Miriam E. Tucker

August 28, 2013

Nearly 1 in 5 children and adolescents with type 1 diabetes (T1D) — and 1 in 4 females — has disturbed eating behavior (DEB), a large survey conducted in Norway found.

The results were published online August 20 in Diabetes Care by Line Wisting, a PhD candidate and researcher at the Regional Eating Disorders Service, Oslo University Hospital, Norway, and colleagues.

"It is recommended that adolescents with T1D should be routinely and annually screened for disordered eating behavior," Ms. Wisting told Medscape Medical News.

In the study, DEB refers to both clinical and subclinical eating disorders. When present in patients with type 1 diabetes, DEB can severely impair metabolic control, accelerate the development of diabetes complications, and is associated with increased mortality, the authors note.

"DEB has shown to be persistent and worsen over time in patients with T1D, suggesting that early intervention is very important to minimize the risk of diabetes complications," Ms. Wisting noted.

Whereas most previous studies looking at this phenomenon in patients with type 1 diabetes have used generic measures of eating disorders, this study is the first to assess prevalence of DEB in youth with type 1 diabetes using the newly developed 16-item Diabetes Eating Problem Survey-Revised (DEPS-R).

The use of diabetes-specific screening tools is important because many of the flagged behaviors suggesting eating disorders in the general population — such as eating when not hungry or preoccupation with food — are natural manifestations of type 1 diabetes. Conversely, the generic tools don't assess diabetes-specific problem behaviors such as insulin restriction.

"The DEPS-R takes less than 10 minutes to complete, is easy to administer, and gives important information about healthy/unhealthy eating habits. It could be an important addition to standard diabetes care in a busy clinical setting. The results of the DEPS-R might give valuable information about the direction of further follow-up," Ms. Wisting told Medscape Medical News.

Disturbed Eating Worsens Diabetes Control

The DEPS-R was administered to 770 youth aged 11 to 19 years who were recruited from the Norwegian Childhood Diabetes Registry, which includes more than 95% of all young patients in Norway with type 1 diabetes. Whereas many other DEB studies have focused primarily on females, males made up half (49.4%) of this study sample.

The group had a mean age 14.6 years, and mean diabetes duration of 5.3 years. Most used insulin pumps (56%) or took at least 4 insulin shots per day.

Using a predetermined cutoff of 20 or higher on the DEPS-R (each item is rated on a 6-point scale), the researchers identified DEB in 18.3% of the entire group, 27.7% of the females, and 8.6% of the males.

The proportions were dramatically higher among the older group of 153 patients aged 17 to 19 years, in whom DEB was identified in 32.7% overall and in 49.4% of the females and 14.5% of the males. In contrast, all of those rates were less than 10% among the 11- to 13-year-olds.

Overweight youth were much more likely to have DEB, with rates of 28.9% among the 147 classified as overweight and 38.1% of the 22 obese youth, compared with just 14.9% of the 533 with normal weight. The relationship between DEB and body weight was particularly strong among the females.

Hemoglobin A1c levels were significantly higher among the patients with DEB compared with those without, 9.2% vs. 8.4% (P < .001).

Nearly a third (31.6%) of the total group endorsed the DEPS-R item "When I overeat, I do not take enough insulin to cover the food," and 6.9% endorsed "After I overeat, I skip my next insulin dose." Among females, 36.8% reported restricting and 26.2% reported skipping insulin after overeating, while those proportions among males were 9.4% and 4.5%, respectively.

Hemoglobin A1c was also significantly higher among those who reported insulin restriction, 9.0% vs. 8.3% (P < .001).

Clinical Implications

Ms. Wisting said that she "was a bit surprised about the high frequency of DEB, especially among the highest age group. However, it is important to note that DEB in this study does not indicate an eating-disorder diagnosis, [but] that the person shows some degree of disturbed eating that should be further assessed."

Furthermore, she noted that the cutoff value of 20 has not been validated. "It might be that the cutoff is set too low and that the prevalence of DEB is therefore artificially high. This needs to be investigated further."

However, in their paper, Ms. Wisting and her colleagues point out that study subjects who scored high on the DEPS-R also scored high on the Eating Attitudes Test, a generic screening measure of disordered eating that was also administered during the study.

Moreover, they note, other investigators have suggested that the cutoff values of the DEPS-R should be intentionally set low in order to identify those at risk as early as possible.

Ms. Wisting told Medscape Medical News, "Unfortunately, there is little knowledge about efficient treatment approaches for this patient group, but collaboration between diabetes and eating-disorder clinicians is very important. I think it is important to include psychologists on the diabetes teams."

This study was funded by the Research Council of Norway. The Norwegian Childhood Diabetes Registry is fully funded by the Health Region South-East. The authors have reported no relevant financial relationships.

Diabetes Care.Published online August 20, 2013. Abstract

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