Have you ever worked with a young lady with type 1 diabetes who has unexplained elevations in A1C, repeated problems with DKA intermixed with fear of weight gain?
Since the 1970s, there have been reports of disordered eating among patients with type 1 diabetes, with mixed results on the frequency. In a recent large multi-centered, case-controlled study of girls aged 12-19, eating disorders were twice as common in girls with diabetes then in their peers without diabetes (Jones et al, 2000).
Speculation continues on the etiology: be it the required focus on eating and counting foods; the effects of a chronic medical condition on self image; or the increased average weight associated with type 1 diabetes compared to controls. Common sign of disordered eating in young women with type 1 diabetes include: poor adherence to one or more treatment regimens, poor metabolic control with elevated A1C; recurrent symptoms of hyperglycemia, recurrent episodes of ketoacidosis, growth retardation and pubertal delay (Turner and Peveler, 2005). It is common enough that there are several inpatient centers in the country that now specifically treat the dual conditions of eating disorders and type 1 diabetes.
Routine questions to consider when working with the at risk population include: binge eating episodes, intentional omission of insulin, laxative use/abuse, dieting for weight control, and any purging behavior. Probably of gravest concern is the opportunity to control weight by deliberate insulin omission, inducing hyperglycemia and glycosuria. Studies report frequency of insulin omission from 13-39% of preteens through young adulthood. In one study, there was a threefold increase in the risk of diabetic retinopathy with persistent eating disorders. Retinopathy was more closely related to disordered eating status than duration of diabetes (a well documented marker) (DCCT Research Group, 1993).
We, as diabetes educators, need to think about the possibility of a co-existing condition of eating disorders or intentional insulin omission when working with teens with type 1 diabetes. Interestingly, I have a delightful teacher with type 1 diabetes that I work with who states “don’t all teens with type 1 diabetes have an eating disorder? I sure did!” I have a number of patients in my practice who admit to disordered eating behaviors, however, I believe there are many more that are practicing bulimic behavior. Hopefully, I will take the time to ask the questions that may open the door to recognition and effective treatment.
What screening tools have you used in your practice? Do you have a team approach? Do you refer dual disorders to another practitioner? Share your stories, so we can all learn from them.