Researchers urge better screening for disordered eating.
There has long been interest, agreement, and disagreement about the co-occurrence of eating disorders, and diabetes. As noted in an editorial in a special issue of the Journal of Eating Disorders in July (J Eat Disord. 2019; 7:27), women with type 1 diabetes mellitus (T1DM) have more than twice the risk of developing an eating disorder than do women without T1DM (Br Med J. 2000;320:1563). A series of recent reports have sought to clarify the connections between T1DM and type 2 diabetes mellitus (T2DM), and factors that may increase the risk for developing binge-eating.
The reasons for increased risk of eating disorders among women with T1DM are still being investigated. Depression and changes in body mass index, or BMI, may play a role. Some aspects of diabetes management may also increase the risk of eating disorders. For example, management entails a focus on carbohydrate intake and portion sizes, which can parallel rigid thinking about food, weight, and body image often reported by women with eating disorders. These treatment basics can lead to feelings of deprivation, resentment, and shame and to binge-eating. In addition, the challenges of maintaining a relatively low hemoglobin A1c values (which can diminish risk of diabetes mellitus complications) can be discouraging to patients. Such a target may seem unattainable for some patients, and may lead them to give up on self-management of T1DM.
Objective binge-eating among adults with T1DM
Objective binge-eating is common among those with T1DM and may negatively affect glycemic control. A team from Duke University Medical Center examined real-time emotional precursors assessing mood and eating behavior using a telephone-based survey system (J Eat Disord. 2019; 7:7). The 83 study participants, most of whom were middle-aged and female (mean: 42 years of age; 87% female) were prompted to rate momentary affect, including their level of diabetes distress. The surveys were done at random intervals; participants were also asked to report on eating episodes. The participants also wore glucose monitors so the researchers could simultaneously (and continuously) assess glycemic control.
The authors reported that individuals who tended to experience negative affect and diabetes-related distress before eating were at increased risk of objective binge-eating at the next meal. The results also suggested that binge-eating may result in even greater subsequent negative affect, including diabetes distress, and can lead to elevated postprandial blood glucose levels. The authors suggest that interventions focused on helping individuals cope with negative emotions and diabetes distress may be helpful to incorporate into treatment for binge-eating.
Binge-eating and glycemic control in T2DM
A team of Brazilian researchers led by Dr. Marcelo Papelbaum of Federal University of Rio de Janeiro and the State Institute of Diabetes and Endocrinology recently followed 70 consecutive patients (18 to 65 years of age) with T2DM to look for a relationship between glycemic control and binge-eating (J Eat Disord. 2019; 7:30). Previous studies have yielded inconsistent results, so more data are of value.
The study sample was mostly female (77%) and married (70%), and the majority had fewer than 9 years of education. The mean BMI was 30.6. Half the patients were obese (34.8); 22 were overweight (27.9) and 13 were of normal weight (mean BMI: 23.6). Overall, the participants had had their diabetes for a mean of 13 years, and had high rates of neuropathy (22%), retinopathy (42%), and nephropathy (52%); more than half were using insulin regularly.
Eating disorders were seen in 20%, and the most common was binge-eating disorder (BED), reported in half of those who had eating disorders. Three had been diagnosed with bulimia nervosa and 4 had an eating disorder not otherwise specified (EDNOS), with subclinical BED. The rate of an eating disorder was definitely linked with BMI: while those with BMIs <25 had a rate of eating disorders of 8%; obese individuals had a 26% prevalence of eating disorders.
In this study, levels of A1c and fasting blood glucose (FBG) were higher in those with an eating disorder. However, after controlling for BMI, the associations lost significance. The authors added that when evaluating glycemic control, levels of A1c and FBG can behave somewhat differently. However, they underscore that these levels measure different aspects of glycemic control. A1c levels represent 2-to 3-month average blood glucose concentrations. Regular FBG measurements, which indicate acute glycemic control, may not match A1c levels, due to such factors as late evening binge-eating, which raise FBG, coupled with daytime food restriction, which can lower Alc levels. Overall, the authors’ findings match those of some previous studies that did not find an association between eating psychopathology and general diabetes clinical or treatment features. They concluded that although the objective negative clinical impact of an eating disorder on patients with T2DM is still being studied, “it is possible to speculate that the remission of binge episodes could play a major role in diabetes treatment.”
The SEARCH for Diabetes in Youth Study
In this large study of a diverse group of youth and young adults with type 1 or type 2 diabetes who were receiving insulin therapy, Dr. Angel S. Y. Nip and colleagues evaluated glycemic control, insulin sensitivity, and psychosocial functioning (Diabetes Care. 2019; 42:859). Disordered eating behaviors were identified in 21.2% of those with T1DM and in 50.3% of participants with T2DM. Most participants had challenges maintaining a healthy weight while controlling their diabetic symptoms. There were some symptoms in common in those with both types of diabetes, plus disordered eating, such as significantly higher BMIs, lower insulin sensitivity, more depressive symptoms, and poorer quality of life than those without disordered eating behaviors. Cases of diabetic ketoacidosis were more frequent in younger patients with T1DM and disordered eating behaviors than in those without disordered eating behaviors. This large and broad study underscores the high frequency of those with diabetes mellitus.
Disordered eating in early-onset, long-term diabetes in teens
In another study, Dr. Christina Baechle and colleagues at the German Center for Diabetes Research, Dusseldorf, Germany, analyzed the prevalence and longitudinal course of disordered eating behavior in adolescents with early-onset, but relatively long-term diabetes (14.9 years duration on average) (J Adolesc Health. 2019; Aug 29: epub ahead of print). The authors searched for age-specific disordered eating patterns and for predictors of the current disordered eating pattern using a diabetes-adapted version of the SCOFF questionnaire.
Dr. Baechle and colleagues found an overall disordered eating prevalence of 10.8% (1318 observations), and a pattern of age-specific differences in the prevalence of symptoms. Onset of or persistence of disordered eating behavior was twice as common among female as among male participants.
As with the authors of the other studies, Dr. Baechle and her co-workers noted that their study results underscore the importance of regular screening for disordered eating among adolescents and young adults with diabetes.