Eating Disorders in Children and Teens with
Type 1 Diabetes
1984-ongoing
Denis Daneman
University of Toronto
And
The Hospital for Sick Children
ED Classification
• Clinical/full-blown: DSM-lV:
– Anorexia nervosa
– Bulimia nervosa
– Eating Disorder Not Otherwise Specified
(EDNOS)
• Subthreshold (not subclinical)
– Disturbed Eating Behavior that does not meet
criteria for full-blown ED, but with clinical
consequences (e.g. A1c, complications)
Working Model:
Rodin & Daneman 1992
Diabetes-specific
vulnerabilities:
Individual,
family, and
societal
factors
Insulin-related weight
gain
Nutritional counseling
Poor self-esteem
Eating Disorders:
Core Features:
Body dissatisfaction
Drive for thinness
Dietary restraint
Disordered eating
attitudes and behavior:
Diabetes-specific outcomes:
Poor metabolic control: high HbA1c
Microvascular complications,
e.g., retinopathy
Insulin omission
Binge eating
Dieting
Predictions arising from our model:
1. Prevalence
2. Natural history
3. Associated with
•
•
•
•
poorer control
specific behavior, especially insulin omission
early complications
specific family issues
4. Difficult to treat
Jones et al, BMJ 2000:
DSM-IV diagnosable ED
• DM: 356
– DSM-IV: 36 (10%)
• AN 0 (0)
• BN 5 (1.4)
• NOS 31 (8.7)
• Controls: 1098 (3:1)
49 (4%)
<.001
0 (0)
NS
5 (0.5)
NS
44 (4.0) <.001
OR =
2.4
(1.5-3.7)
Jones et al, 2000:
Subthreshold Disorders:
• DM: 356
– 49 (14%)
• Controls: 1098
84 (8%)
<.001
OR = 1.9
(1.3-2.8)
DSM-IV + ST
85 (24%)
134 (12%)
OR = 2
Obstacles identified during initial assessment
Intrapersonal Barriers
Number (%)
Mental health issue in teen (total)
Weight and shape concern
Low Mood
Anxiety
Substance abuse
Oppositional behavior
25 (81%)
18 (58%)
10 (32%)
6 (19%)
3 (10%)
2 (6%)
Fear of Hypoglycemia
6 (19%)
Learning and attention problems
4 (13%)
Significant knowledge deficit
0
Interpersonal Barriers
Single Parent Family
13 (42%)
Inadequate or ineffective parental support
29 (94%)
Family systems difficulties
26 (84%)
Mental health issues in parent(s)
10 (32%)
Financial stress
13 (42%)
*multiple obstacles were identified in the majority of these subjects
HbA1c (%)
HbA1c by Disordered Eating Status at
Baseline and Follow-up.
11.5
11
10.5
10
9.5
9
8.5
8
7.5
7
6.5
6
Baseline
Follow-up
*Highly
disordered**
Moderately
disordered**
Non-disordered
*HbA1c for the highly disordered group was significantly higher than the moderately and non-disordered
groups at baseline, p<.001;
**HbA1c for the highly and moderately disordered groups was significantly higher than the non-disordered
group at follow-up, p<.005 (Rydall et al., 1997).
Common behaviors in girls with type 1
diabetes.
100
90
80
70
60
50
40
30
20
10
0
Baseline
Follow-up
Binge *Dieting **Insulin ***Self- Laxative
eating
omission induced use
vomiting
McNemar’s test for change in prevalence, baseline to follow-up:
*p=0.01; **p=0.003; ***p=.06 (Rydall et al., 1997).
Prevalence of Insulin Omission (%)
Age and Prevalence of Insulin Omission
for Weight Control.
40
30
Insulin
Series1
Omission
20
10
0
1
9-13 years
1Colton
2
3
12-18 years 16-22 years
et al., 2000 (n=90): 1% prevalence of insulin omission in pre-teen girls;
et al., 1997 (n=91): 14% in adolescent girls (baseline assessment);
3 Rydall et al., 1997 (n=91): 34% in young adult women (four-year follow-up of
baseline sample).
2 Rydall
Evolution of ED in teen girls with T1D
• In progress, study of natural history of ED in
girls with T1D;
– Baseline: 101 9-13.9 yo with T1D & 303 controls
– Follow-up of DM cohort for 5-8 years
• Demographics at Baseline:
– Mean age
– Mean A1c
– Mean duration of T1D
11.8 years
8.2%
4.7 years
DISTURBED EATING BEHAVIOUR
(last month)
20
16
*
12
%
*
8
4
0
Diet
Intense
Exercise
Binge
Insulin 1 or more 2 or more
Omission
T1D
School
EATING DISORDERS:
T1D VS. SCHOOL GIRLS
10
8
%
sample
6
p = .001
ED-NOS
SUBTHRESHOLD
4
2
0
T1D
School
No sign differences in:
•Age
•A1c
•Duration of T1D
Those with ED BMI >
those without
FIVE-YEAR FOLLOW-UP
• 13.3% of participants (13/98) met criteria for
an ED
• 3 girls had bulimia nervosa
• 3 had ED-NOS
• 7 had a subthreshold ED
• 44.9% of participants were classified as
overweight or obese
FIVE-YEAR FOLLOW-UP
• A1c not higher in girls with DEB
–(8.7% vs. 8.4%; p = 0.11)
• Trend for higher A1c in those
with an ED
–(9.1% vs. 8.5%; p = 0.08)
• BMI higher in those with DEB
–(26.1 versus 23.5; p = 0.001)
ED POINT PREVALENCE &
CUMULATIVE PREVALENCE BY AGE
50
45
40
35
30
% 25
20
15
10
5
0
ED point prev
ED cumulative
9
10 11 12 13 14 15 16 17 18 19
Age
FIVE-YEAR FOLLOW-UP
• Higher BMI and DEB were strongly
associated, which presents a
management dilemma
• Both dietary restraint and higher
weight are risk factors for the
development of ED and their negative
health consequences
PREDICTION OF THE
ONSET OF DISTURBED
EATING BEHAVIOUR IN
ADOLESCENT GIRLS
WITH TYPE 1 DIABETES
LOGISTIC REGRESSION MODEL WITH
BACKWARD STEPWISE REGRESSION
Dietary Restraint
Weight & Shape Concern
Physical Appearance
Self-Worth
Depression
X2 = 43.254, df = 5, p<.0001
McFadden’s R2 = 0.416
If the model is correct, then the prevalence of
complications should be more common in ED:
100
80
60
Highly
Disordered
40
20
0
Retinopathy*
MicroAlbuminuria
(Rydall et al., NEJM 1997).
Moderately
Disordered
Non-Disordered
Is family dysfunction more
common in ED than nonED DM:
To investigate if and how eating
disturbances in girls with type 1
DM are associated with:
1. Mother’s weight and shape
concerns
2. Mother-daughter relationships
3. Adolescent self-concept
Method
TEENS (N=88)
MOTHERS (N=88)
• Age = 14.9 yrs. (+ 2.2)
• Age = 43.7 yrs (+ 5.5)
• Weight = 58.9 kg (+12.7)
• Weight = 69.3 (+13.7)
•
•
BMI = 22.4 kg/m2 (+3.7)
• Age of Diabetes Onset =
7.9 yrs (+ 4.0)
• Illness Duration =
7.1yrs (+3.9)
• HbA1c = 8.9 % (+ 1.6)
BMI = 25.9 (+4.9)
• Middle Class
• Completed 1-2 years of
college, university, or
specialized training
Perceived Relationships With
Mothers
Non
40
35
30
25
20
15
10
5
0
Communic.
Alienation
Communic.Trust
Trust Alienation
Mildly
• Multivariate Group effect
[F(6, 160 ) = 3.97,
p =.001]
Highly
Highly & Mildly Disturbed
girls report more impaired
relations with mothers on
all dimensions compared
to Non-Disturbed girls
(p = .01)
Figure 8: Observed Mother-Daughter Interaction Patterns.
Non
•
MANCOVA illustrated a
significant Group effect
(p=.0005), with all three
groups differing from each
other on Mother Autonomy
(p=.001), Adolescent
Autonomy (p=.01) &
Intimacy (p=.0005).
•
There was a significant Task
effect (p=.0005), with more
impairment in Adolescent
Autonomy (p=.0005) and
Intimacy (p=.001) during
diabetes-related discussions.
M ildly
Highly
5
4.5
4
3.5
3
2.5
2
1.5
1
0.5
0
M other
Autonomy
Teen
Autonomy
Intimacy
(Maharaj et al., in press)
Mother’s Eating and Weight Loss
Behaviors
4.8
4.3
3.8
3.3
2.8
2.3
1.8
1.3
0.8
0.3
-0.2
Sa
tis
fie
Ex d
erc
ise
Di
et
Bi
ng
e
Satisfaction Diet
Exercise Binge
Non
Mildly
Highly
• Multivariate Group effect
[F (10, 138) = 2.12, p = .03]
• Mothers of Highly &
Mildly Disturbed girls are
more weight dissatisfied
(p = .01) and are more
likely to exercise for
weight control (p = .02),
diet (p = .05), and binge
eat (p = .02).
Prevention and Treatment in DM
and ED:
• Prevention: not reported
• Treatment:
–CBT - Peveler and Fairburn 1989
–Fluoxetine - case report - 1990
–Psychoeducation - Olmsted 2000
Evidence-based conclusions:
Model validation
• Eating disorders are more common in
adolescent and young adult females with
diabetes (Level 1)
• When present they are associated with
– high frequency of insulin omission (Level 1)
– worse metabolic control (Level 2)
– earlier onset of complications (Level 1)
– family dysfunction (Level 2)
• They are (more) difficult to treat (Level 4)
Approach to ED in DM
• Awareness of the association
• Ask the “right” questions
• If suspect “fullblown” ED refer
• If subthreshold - clinic-based
intervention
• Complication surveillance
Asking the “right” questions
“Red flags”
 Dealing with reluctance to disclose
 Their stories…
 Partnering with patients
 Regaining control
 Treatment options

Red Flags
Persistently high A1c
 Frequent DKA, illnesses
 Distress re: weight
 Widely fluctuating b.g.s
 Skipping meals
 “Binging”; feeling hungry all the time
 Skipping dosing/underdosing

Initial response to high A1c:
Raise the dose
 Labeled “insulin
resistent”
 Problem: “insulin
avoidant”

Disclosure is very difficult
Shame
 Feel like “failures”
 Failed:





Their families
Their providers
Themselves
Important to be
nonjudgemental
and supportive
In their words….
A start….

Information can be helpful
 “Unfortunately
something many young
people struggle with…”
 Insulin omission drives hunger
 Losing control over eating behavior

Information for parents
 Families
are angry, blaming
 They feel like failures too
Regaining control
A step at a time
 Steps forward, steps back
 Treatment options:


Partner with existing ED programs

Requires collaboration
Groups
 Conventional treatment
 Medication/Consult
