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R e v i e w s / C o m m e n t a r i e s / A D A S t a t e m e n t s
Disordered Eating Behavior in Individuals
With Diabetes
Importance of context, evaluation, and classification
DEBORAH L. YOUNG-HYMAN, PHD
PREVALENCE OF
CATHERINE L. DAVIS, PHD
DIAGNOSABLE EATING
DISORDERS AND DEB
IN PATIENTS

Thisreviewwasconductedtoexam- weightconcerns,DEB,andeatingdisor- WITHDIABETES— Controversyexists
ders are at a high prevalence (1). Recent studies have included type 2 diabetic pa- disorders, in the context of diabetes. The tients, minorities, and male patients (2– standardized on the healthy population is associated with elevated rates of DEB and (1,8,19). Rates similar to (1,8,23–25) and examined. Also considered is the need for eating disorders, particularly when insu- fication of this behavior when evaluating patients with diabetes. Future directions rates of diagnosable eating disorders but higher rates of DEB, particularly bulimia poorer health in individuals with type 1 di- present was examined using “eating dis- orders and diabetes” as search terms.
abetes. Early reports found prevalence rates of the co-occurrence of diabetes and DEB to range from 3.8% (12)–27.5% for patients be low and accompanied by psychiatric co- views, PsycInfo, etc. Bibliographies from articles were reviewed to ascertain addi- control was not compromised (12–14).
tional publications. Cited articles include reviews and individual studies indicating tween elevated A1C and diagnosable eating healthy control, or population estimate), disorders (2), subclinical DEB (8), and in- tentional insulin omission (1). The presence tionnaires, and structured/clinical inter- of diagnosable eating disorders and behav- ior categorized as subclinical DEB has been criteria. Not all relevant articles could be (15), neuropathy (16), transient lipid ab- normalities (17), hospitalizations for dia- and diagnosable eating disorders are vari- betic ketoacidosis (6), and poor short-term metabolic control (1,6,8,18). Studies as- of DEB in the population of patients with sessing the association of DEB and eating disorders with long-term metabolic control have produced mixed results (6,19 –22). A status is a strong predictor of eating dis- prospective 5-year study did not find a sig- nificant relationship between DEB or eating disorders and poorer glycemic control (22).
1 diabetic cohorts studied have been sig- Less is known about the relationships be- tween DEB and health status in individuals groups, with the average BMI above thenormal range (1,19). To compare an age- ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● From the 1Department of Pediatrics, Georgia Prevention Institute, Medical College of Georgia, Augusta, tients, the EDE (32) was administered.
Corresponding author: Deborah Young-Hyman, [email protected]
Received 15 June 2008 and accepted 18 December 2009.
DOI: 10.2337/dc08-1077 identified. However, using the Diagnostic 2010 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. See http://creativecommons.
ders, 4th edition (DSM-IV) criteria, which org/licenses/by-nc-nd/3.0/ for details.
The costs of publication of this article were defrayed in part by the payment of page charges. This article must therefore be hereby marked “advertisement” in accordance with 18 U.S.C. Section 1734 solely to indicate this fact. rates were identified in the diabetic sam- DIABETES CARE, VOLUME 33, NUMBER 3, MARCH 2010 Disordered eating behavior and diabetes
ple. Average BMI Z score was higher (P ϭ eral satiety mechanisms via its effects on able eating disorders (26). In the 5-year INSULIN AND WEIGHT
bolic signals to regulate food intake.
follow-up study of type 1 diabetic patients GAIN — As glycemic control improves,
Acute anorectic effects of amylin include eating disorders. Mannuci et al. (5) com- successful treatment with insulin (36).
activity. Amylin is also thought to play a tensive treatment results in weight gain as patients seeking weight loss, and an obese (41,42). Amylin, insulin, leptin, and glu- (1,6,8,37). Increasing weight can require cagon act synergistically with cholecysto- all three samples, low levels of BED were gogue treatment to control blood glucose, poglycemia, and dietary intake (38).
scores (5). Only one study was found that stratified the diabetes cohort (type 1 and 2 diabetic, male and female, ages 18 – 65 years) by weight status; 3% of under- and naire and interview data, type 1 diabetic females were significantly heavier (6.8 kg) considered potential therapies for condi- tions related to obesity and DEB (44).
able eating disorders (27). These rates are might be a response to overinsulinization hances feelings of satiety, reducing food intake and causing weight loss in patients both “strongly activate appetite regulation tion of supraphysiological levels of insulin Revision (TR) (33) criteria such as binge as contributing to overeating and insulin betic men, levels of postprandial insulin reduce appetite has not been explored.
and intense exercise for weight control are determinants of short-term appetite regu- lation (46). Miglitol, a second generation with type 1 diabetes (22,23). In the 5-year insulin dosing and lower the need for in- evaluate its effect on glucagon-like pep- patients reporting subclinical DEB ranged from 3–26% depending on the behavior.
suppressed GIP, increased satiety, and de- for male patients are lower but appear to and questions regarding efforts to control be changing. Svensson et al. (34) studied studies of incretins in type 1 diabetic pa- scribed. There were no differences in rates girls with type 1 diabetes who were using and scores on the Drive for Thinness Scale normal limits for both groups and did not tain a normal between-meal interval (48).
DEB in the context of physiological mech- with dysregulation of appetite and satiety patients with diabetes (34). Studies using type 2 diabetic patients show similar rates ations due to diabetes pathophysiology or (9,35). However, types of reported cogni- DYSREGULATION OF
tions and behaviors differ. “Drive for thin- SATIETY — Destruction of ␤-cells results iors. The DSM-IV-TR classification sys-
ness” and “body dissatisfaction” were in the inability to secrete both insulin and appetite and satiety. Amylin mediates sev- DIABETES CARE, VOLUME 33, NUMBER 3, MARCH 2010 Young-Hyman and Davis
Table 1—Adapted from the DSM-IV-TR: necessary diagnostic criteria for eating disorders
(axis-1)
binge. DSM-IV-TR criteria state: “Individ- Anorexia nervosa: rare in individuals with diabetes.
Refusal to maintain body weight at or above a minimally normal weight for age and height (e.g., weight loss leading to maintenance of body weight Ͻ85% of that expected or failure to make expected weight gain during period of growth, leading to body during eating binges” (33). Refinement of criteria to include the effects of treatment Intense fear of gaining weight or becoming fat, despite being underweight.
Disturbance in the way in which one’s body weight or shape is experienced, undue influence of body weight or shape on self-evaluation, or denial of seriousness of the Bulimia nervosa: low prevalence rate of diagnosis but commonly reported behavior in Recurrent episodes of binge eating, characterized by: Eating, in a discrete period of time (e.g., within any 2-h period), an amount of food that DEB in patients with diabetes may also be is definitely larger than most people would eat during a similar period of time and A sense of lack of control over eating during the episode (e.g., a feeling that one cannot CLASSIFICATION:
stop eating or control what or how much one is eating).
ADHERENCE
Recurrent inappropriate compensatory behavior in order to prevent weight gain, such as NONCOMPLIANCE, OR
self-induced vomiting; misuse of laxatives, diuretics, enemas, or other medications DISTRESS — Behaviors considered
(insulin omission); and fasting or excessive exercise.
Binge eating and inappropriate compensatory behaviors both occur, on average, Ն2 (49). Behaviors and attitudes such as di- Self-evaluation is unduly influenced by body shape and weight concerns.
etary restraint, food preoccupation (car- Eating disorder not otherwise specified (EDNOS): more commonly diagnosed in individuals with diabetes and includes disorders of eating that do not meet the criteria for any portion control, and control of blood sug- All of the criteria for bulimia nervosa are met except that the binge eating and inappropriate compensatory mechanisms occur at a frequency of Ͻ2 episodes per week or for components of diabetes care (39,50).
The regular use of inappropriate compensatory behavior by an individual of normal body of blood glucose, characterize successful weight after eating small amounts of food (e.g., self-induced vomiting after the weight loss treatment (51). Behaviors be- consumption of two cookies or insulin omission or reduction after consumption of Binge eating disorder (BED): most prevalent diagnosis in individuals with diabetes.
for rapid weight loss, are carried to excess, Recurrent episodes of binge eating. An episode is characterized by eating a larger amount of interfere with activities of daily living, or food than normal during a short period of time (within any 2-h period) and lack of control over eating during the binge episode (i.e., the feeling that one cannot stop the context of diabetes care, strict adher- ence to these behaviors provides tools by Binge eating episodes are associated with three or more of the following: Eating until feeling uncomfortably full.
Eating large amounts of food when not physically hungry.
Eating much more rapidly than normal.
EDI-III, and Diagnostic Survey for Eating Eating alone because you are embarrassed by how much you are eating.
Feeling disgusted, depressed, or guilty after overeating.
pation and restriction could initially be Marked distress regarding binge eating is present.
identified as DEB in patients with diabe- Binge eating occurs, on average, Ն2 days per week for Ն6 months.
The binge eating is not associated with the regular use of inappropriate compensatory behavior (i.e., purging, excessive exercise, etc.) and does not occur exclusively tion by an individual familiar with the di- during the course of bulimia nervosa or anorexia nervosa.
abetes self-care regimen may be needed tofurther elucidate the intent and relation-ships between endorsed behaviors and (53). The essential criterion for BED is re- evaluation of eating disorders. Illustrating peatedly eating amounts of food in a short period of time that are “larger than most cumstances.” Because DEB is rarely quan- tified by direct observation, this criterion porting of dietary intake to be 47%.
follow a prescribed dietary plan have been cantly associated with BMI and waist cir- encing loss of control of eating behavior DIABETES CARE, VOLUME 33, NUMBER 3, MARCH 2010 Disordered eating behavior and diabetes
DEB. It has been speculated that difficulty adjusting to the diabetes self-care regimen report dietary intake. Studies that evalu- morbidity between increased psychological distress and diabetes (61) and symptoms of associated with their weight status could tion in relationships with care providers (58), findings suggest that assessment of sonality characteristics in the context of symptoms of DEB are considered (12).
of other psychological, familial, or soci- intake include eating too much or too lit- tle relative to glycemic status and insulin dose, overconsumption of food to treat or girls and boys, ages 8 –13 years, from di- tion from the prescribed insulin treatment agnosis up to 14 years of age, Pollock et al.
adjustment to the illness. DEB criteria and to take compensatory insulin (55). Inten- to assess the range of self-treatment be- tional insulin reduction or omission rela- haviors relevant to patients with diabetes times more likely to have had a psychiat- various studies (2,21). However, the def- ric disorder than the rest of the patients.” initions of what constitutes insulin omis- tential validity of screening measures and specific to the diabetes care regimen. Reg- central to diabetes treatment may also be part of a constellation of pervasive non- ment of DEB. Feelings of loss of autonomy and control are associated with the devel- the Structured Clinical Interview and the MEASUREMENT OF DEB
opment of eating disorders in nondiabetic AND EATING DISORDERS — A
individuals seeking weight loss (31). The review of representative literature indicated that questionnaires (9,34,37,49,62), inter- in patients with diabetes (53). Issues for consideration include but are not limited to: feelings of loss of control because of patients with eating disorders had signif- used to identify presence of DEB in stud- ies of individuals with diabetes. All stud- glucose, feeling loss of autonomy because (4). Distress, particularly depression, may et al. (62), have used instruments and in- terview techniques developed and/or stan- dardized in the nondiabetic population to the difficulty of adhering to the diabetes ability to health care providers regarding care regimen (8). Herpertz et al. (7) con- ducted a cross-sectional study of the rela- are not limited to the Eating Attitudes Test (56), and weight gain due to the initiation sociation with weight-related distress but tion is gathered via clinical interview for istics and DEB (57–59). Characteristics studied include coping styles (60), unmit- igated communion (putting others’ needs with depression and low self-esteem (7).
to categorize behaviors as eating disorders loss have shown that the onset of DEB can weight precedes weight concerns is illus- tients. BMI was tracked concurrently with DIABETES CARE, VOLUME 33, NUMBER 3, MARCH 2010 Young-Hyman and Davis
underscored for individuals with diabetes to hypoglycemia. If the question is posed those seeking to prevent weight gain sec- of the question querying the intent of and psychologist with type 1 diabetes to iden- tify questions that could be answered af- firmatively in the context of diabetes self- considered adaptive rather than a purge of the potential for misclassification of be- consume?” and “I eat a lot of food when calories via glycosuria (10). The EDE asks I’m not even hungry” are BULIT-R ques- after behavioral intent, associated mood, when they possibly reflect skills and atti- tions (used in studies by Affenito et al.
and thoughts. However, the contribution of tudes learned as part of the diabetes care/ [17,18]) that directly relate to the diabetes the diabetes care regimen, diabetes self- of dietary restraint and the latter by use of exogenous insulin. A later question, “I feel not routinely assessed to determine their methods that address diabetes-specific at- that food controls my life,” could be en- contribution to weight-driven behaviors or titudes, concerns, and behaviors that are dorsed by any individual with diabetes.
prescribed as part of treatment; as well as dardization of questionnaires and interview for Thinness Scale include, “I eat sweets formats to determine the motivation and in- tent of behaviors in the diabetes population vous,” and “I feel extremely guilty after will increase diagnostic accuracy in the con- of subjects that were white, heavier than overeating.” Three of seven questions on Engstrom et al. [19] to evaluate females, (DEPS), created by Markowitz et al. (62), justment specifically for the purposes of selection bias may be operating to elimi- dieting that could be answered in the con- text of having and treating diabetes were in terms of diabetes care. Issues related to viduals from clinical studies, potentially gain are specifically identified and ques- could potentially be endorsed in the con- satiety and fullness in the context of insu- the time of diagnosis to establish the tem- lin dosing, blood glucose levels, and eat- would likely meet criteria for the presence weight gain occurs first or the care regi- (used by Rydall et al., [15] and Jones et al., the use of well-established DEB criteria, prescription, adjustment to illness, hun- patients due to items that reflect the dia- Evaluation, characterization, and classifi- cation of DEB in individuals with diabetes patients who are hesitant to reveal treat- sification of these behaviors is less clini- that relate to their regimen. It has been criteria and taxonomy are not established.
Further, focusing on identified gaps in fu- and criteria to include the effects of dia- ture investigations of DEB in this popula- tion could improve clinical care for this DEB and diabetes include: lack of weight- spectively from diagnosis will allow us to (see Table 1) under the category of purg- assess the contributions of the many fac- ing behavior (27). However, this behavior ing the prevalence of eating disorders or tors that predispose individuals to the de- subclinical DEB; evaluation of the contri- velopment of DEB, potentially identifying butions of an insulin dosing schedule and hunger, improve feelings of satiety, or re- lower risk of iatrogenic complications. It DIABETES CARE, VOLUME 33, NUMBER 3, MARCH 2010 Disordered eating behavior and diabetes
is clinically important to be able to iden- psychiatric comorbidity in a clinical sam- tify those individuals who are at risk for ple of type 2 diabetes mellitus patients.
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