Why children with diabetes are at risk for disordered eating

Patients with diabetes are at risk for developing inappropriate relationships with food, according to new research, highlighting the need for healthcare providers to provide more psychosocial support to this population.

Disordered eating is a general term used to describe a variety of inappropriate eating behaviors to lose weight, according to Angel Siu-ying Nip, MD, a fellow in endocrinology and diabetes at the University of Washington, Seattle, and lead author of the new study that was presented as a poster session at the American Diabetes Association's 77th Scientific Sessions, held in San Diego, California, June 9 to 13, 2017.

Disordered eating occurs in about 30% of adult women with type 1 diabetes (T1D), and Yip says her team believes that children are also vulnerable because of the intense focus on weight control and food that is part of managing their diabetes.

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Researchers conducted the study using data from the SEARCH for Diabetes in Youth Study, which evaluated more than 2000 children and young adults with T1D and type 2 diabetes (T2D). Participants in the study completed the Diabetes Eating Problem Survey-Revised (DEPS-R) questionnaire with 16 diabetes-specific questions particular to children with T1D. Although the questions have not been validated in children with T2D, the researchers believe they are likely relevant in that population as well.

"Disordered eating behavior is common among youth and young adults with [T1D] and [T28/1/17] and is associated with significant health consequences. Twenty-one percent of patients with [T1D] and up to 50% of patients with [T2D] have issues of disordered eating behaviors," Nip says. "A high index of suspicion of the presence of maladaptive behaviors, particularly among those with persistent poor metabolic control, is key. It is important to start screening at early adolescence and develop collaborative and effective interventions for youth and young adults with disordered eating behaviors."

There are a host of concurrent issues that go along with a diabetes diagnosis, including problems that can impact health outcomes and quality of life. Disordered eating, depression, and anxiety are just a few examples, and these are the focus of a new position statement and standards of care document created by the American Diabetes Association. The new documents focus on providing additional education to healthcare providers on how to support patients with diabetes. The documents were presented alongside Nip's study and another study supporting the need for additional psychosocial support at the American Diabetes Association's 77th Scientific Sessions.

Overall, Yip and her team found that 21.2% of the individuals with T1D studied and 52.2% of those participants with T2D had some degree of disordered eating, as evidenced by DEPS-R scores of at least 20. Higher DEPS-R scores also were associated with higher body mass index (BMI), lower insulin sensitivity levels, and more psychosocial problems, according to the researchers.

Findings showed that participants with T2D more frequently reported problems with weight control (60.3% of participants with T2D compared with 31.5% of participants with T1D). Participants with T2D were also more likely to endorse a desire to be thin at the expense of healthy diabetes management (34.2% of those with T2D compared with just 12.4% of participants with T1D). Also, 50.3% of participants with T2D admitted to binge eating compared with 27.5% of participants with T1D. About 20% of participants overall admitted to not taking insulin in order to lose weight.

According to the abstract, participants with T1D who had DEPS-R scores at or above 20 were most often females with higher BMIs and HbA1C scores and lower insulin sensitivity. Participants with T1D who had higher scores were also more than twice as likely to have been in diabetic ketoacidosis in the prior 6 months and to endorse depression.

In participants with T2D, there was nearly an equal number of males and females with DEPS-R scores at or above 20, but other results were similar.

Disordered eating behaviors occurred in children aged as young as 10 to 14 years, Yip adds.

"We, as healthcare providers, should be vigilant and have a high suspicion of the presence of maladaptive behaviors. Providers should educate patients and their families to make sustainable healthful lifestyle choices rather than focus on a specific weight loss goal," Yip says. "We encourage ongoing communications with patients and their families and share our concerns on disordered eating behaviors, and educate the warning signs of developing disordered eating behaviors including unexpected weight loss, worsening of glucose control."

Early recognition is important, according to Yip. She recommends screening for disordered eating behaviors in early adolescence and offering support to promote healthy weight and diabetes management.

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"Patients with diabetes benefit from increased psychosocial support, with the burden of diabetes management and the worry of disease progression. They are also at higher risk of developing disordered eating behaviors with the intense focus on weight and diet control," Nip says. "We recommend psychosocial assessment at diagnosis, routinely thereafter, and any time there are important changes in disease status and in patients’ personal situations. Collaborative support with a multidisciplinary team including social workers, nutritionists, psychologists, and psychiatrists are paramount."