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Diabetes Care. 2010 Mar; 33(3): 683–689.
PMCID: PMC2827531
PMID: 20190297
Importance of context, evaluation, and classification

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1Department of Pediatrics, Georgia Prevention Institute, Medical College of Georgia, Augusta, Georgia.

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Catherine L. Davis

1Department of Pediatrics, Georgia Prevention Institute, Medical College of Georgia, Augusta, Georgia.

Find articles by Catherine L. Davis
1Department of Pediatrics, Georgia Prevention Institute, Medical College of Georgia, Augusta, Georgia.
Corresponding author: Deborah Young-Hyman, [email protected].
Received 2008 Jun 15; Accepted 2009 Dec 18.
Copyright © 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.org/licenses/by-nc-nd/3.0/ for details.
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This review was conducted to examine disordered eating behavior (DEB), including diagnosable eating disorders, in the context of diabetes. The use of criteria and assessment methods standardized on the healthy population is examined. Also considered is the need for modified assessment methods and classification of this behavior when evaluating patients with diabetes. Future directions for research are suggested.

Literature published from 1980 to present was examined using “eating disorders and diabetes” as search for 1 last update 08 Jul 2020 terms. Over 100 peer-reviewed articles were identified via PubMed, Cochrane Reviews, PsycInfo, etc. Bibliographies from articles were reviewed to ascertain additional publications. Cited articles include reviews and individual studies indicating experimental design (self as control, healthy control, or population estimate), assessment methods (self-report, questionnaires, and structured/clinical interviews), and use of standard diagnostic criteria. Not all relevant articles could be included. However, some older references (published before 2000) are included because they provide foundation literature from which our understanding of DEB in the population of patients with diabetes derives and/or are validation studies for measurement methods. Additional references pertinent to hypothesized mechanisms are cited.Literature published from 1980 to present was examined using “eating disorders and diabetes” as search terms. Over 100 peer-reviewed articles were identified via PubMed, Cochrane Reviews, PsycInfo, etc. Bibliographies from articles were reviewed to ascertain additional publications. Cited articles include reviews and individual studies indicating experimental design (self as control, healthy control, or population estimate), assessment methods (self-report, questionnaires, and structured/clinical interviews), and use of standard diagnostic criteria. Not all relevant articles could be included. However, some older references (published before 2000) are included because they provide foundation literature from which our understanding of DEB in the population of patients with diabetes derives and/or are validation studies for measurement methods. Additional references pertinent to hypothesized mechanisms are cited.

Most studies, including those in a 2005 meta-analysis (N = 8 case-controlled studies), tend to focus on young women with type 1 diabetes, usually between ages 15–35 years, when weight concerns, DEB, and eating disorders are at a high prevalence (1). Recent studies have included type 2 diabetic patients, minorities, and male patients (29). The diagnosis of diabetes has been associated with elevated rates of DEB and eating disorders, particularly when insulin omission is considered purging (1,811).

Diagnosed eating disorders and subclinical DEB have been associated with poorer health in individuals with type 1 diabetes. Early reports found prevalence rates of the co-occurrence of diabetes and DEB to be low and accompanied by psychiatric comorbidity and weight loss, but diabetes control was not compromised (1214). More recent cross-sectional studies have demonstrated a positive association between elevated A1C and diagnosable eating disorders (2), subclinical DEB (8), and intentional insulin omission (1). The presence of diagnosable eating disorders and behavior categorized as subclinical DEB has been associated with increases in retinopathy (15), neuropathy (16), transient lipid abnormalities (17), hospitalizations for diabetic ketoacidosis (6), and poor short-term metabolic control (1,6,8,18). Studies assessing the association of DEB and eating disorders with long-term metabolic control have produced mixed results (6,1922). A prospective 5-year study did not find a significant relationship between DEB or eating disorders and poorer glycemic control (22). Less is known about the relationships between DEB and health status in individuals with type 2 diabetes (4,7,9).

PREVALENCE OF DIAGNOSABLE EATING DISORDERS AND DEB IN PATIENTS WITH DIABETES

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When establishing the relative prevalence of DEB in the diabetic population, most studies have not matched control samples for weight (1,19,21,26). Weight status is a strong predictor of eating disorders and DEB among overweight women attempting weight loss (31). Type 1 diabetic cohorts studied have been significantly heavier than comparison groups, with the average BMI above the normal range (1,19). To compare an age- and sex- (but not BMI-) matched control sample to one with type 1 diabetic patients, the EDE (32) was administered. Similar rates of eating pathology were identified. However, using the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV) criteria, which include insulin omission (33), higher rates were identified in the diabetic sample. Average BMI Z score was higher (P = 0.05) in the cohort with diabetes, and higher BMI was associated with diagnosable eating disorders (26). In the 5-year follow-up study of type 1 diabetic patients (22), BMI was the strongest predictor of eating disorders. Mannuci et al. (5) compared overweight and obese type 2 diabetic patients with obese nondiabetic patients seeking weight loss, and an obese non–treatment seeking sample. Among all three samples, low levels of BED were diagnosed (<5%). Obese diabetic pa-tients had the lowest scores on the EDE overall but the highest Restraint Scale 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 normal-weight women had a current eating disorder, whereas 7% of overweight and 10% of obese women had diagnosable eating disorders (27). These rates are similar to those for nondiabetic samples with similar BMI levels seeking weight loss (31).

Subclinical DEB using DSM-IV Text Revision (TR) (33) criteria such as binge eating, self-induced vomiting, insulin omission, excessive caloric restriction, and intense exercise for weight control are commonly reported by female patients with type 1 diabetes (22,23). In the 5-year prospective study by Colton et al. (22), patients reporting subclinical DEB ranged from 3–26% depending on the behavior. Fifty-one percent of the teens assessed multiple times over a 5-year period reported DEB at least once, and early subclinical DEB was found to be highly persistent over time. Rates documented for male patients are lower but appear to be changing. Svensson et al. (34) studied adolescent males with type 1 diabetes compared with healthy control subjects and found no diagnosable eating disorders in either group. Males with type 1 diabetes had significantly higher BMIs and scores on the Drive for Thinness Scale on the Eating Disorder Inventory (EDI), suggesting higher risk for the development of DEB. Bulimia scores were, however, higher in control subjects than in patients with diabetes (34). Studies using questionnaires and structured interviews that compare occurrence in type 1 versus type 2 diabetic patients show similar rates (9,35). However, types of reported cognitions and behaviors differ. “Drive for thinness” and “body dissatisfaction” were more often reported by type 2 diabetic patients, whereas insulin omission was more frequently reported by type 1 diabetic patients (9,35).

INSULIN AND WEIGHT GAIN

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DYSREGULATION OF SATIETY

Destruction of β-cells results in the inability to secrete both insulin and amylin, contributing to dysregulation of appetite and satiety. Amylin mediates several satiety mechanisms via its effects on the area postrema, an area of the brainstem that integrates hormonal and metabolic signals to regulate food intake. Acute anorectic effects of amylin include slowed gastric emptying, reduced glucagon secretion, and lateral hypothalamic activity. Amylin is also thought to play a role in long-term weight regulation (41,42). Amylin, insulin, leptin, and glucagon act synergistically with cholecystokinin to reduce appetite (42). These actions are opposed by ghrelin, concentrations of which are lower in obese and type 2 diabetic patients and higher than would be expected in patients with anorexia nervosa and type 1 diabetes (42,43). Amylin analogs and other hormones affecting the gut-brain axis are considered potential therapies for conditions related to obesity and DEB (44). Pramlintide, an analog of amylin, enhances feelings of satiety, reducing food intake and causing weight loss in patients with diabetes (45).

In a study of other hormonal satiety mechanisms in lean and obese nondiabetic men, levels of postprandial insulin and glucose-dependent insulinotropic polypeptide (GIP) were found to be key determinants of short-term appetite regulation (46). Miglitol, a second generation α-glucosidase inhibitor, was tested to evaluate its effect on glucagon-like peptide I (GLP-1) GIP, insulin-glucose dynamics, and satiety in obese type 2 diabetic women. After a solid meal challenge, type 2 diabetic women taking miglitol had increased GLP-1 response, suppressed GIP, increased satiety, and decreased hunger and food intake versus those taking placebo (47). A review of studies of incretins in type 1 diabetic patients during the remission phase of the disease suggested that the use of long-acting GLP-1 agonists, which modulate insulin dynamics, could help patients stick to their dietary program and maintain a normal between-meal interval (48). No studies were identified that assessed DEB in the context of physiological mechanisms that are known to be associated with dysregulation of appetite and satiety and/or potentiate weight gain.

reverses diabetes type 2 overview (πŸ”΄ recipes) | reverses diabetes type 2 case studyhow to reverses diabetes type 2 for The current DSM-IV-TR definition of DEB does not address hormonal alterations due to diabetes pathophysiology or treatment that may affect eating behaviors. The DSM-IV-TR classification system for DEB defines binging as a loss of control over behavior and insulin omission as a maladaptive strategy to either prevent weight gain or reduce weight via glycosuria without an accompanying binge. DSM-IV-TR criteria state: “Individuals with diabetes and bulimia nervosa may omit or reduce insulin doses to reduce the metabolism of food consumed during eating binges” (33). Refinement of criteria to include the effects of treatment has been suggested by the working group convened during the International Conference on Eating Disorders and Diabetes Mellitus, which met in Minneapolis, Minnesota, in 2008 (49). Consideration of physiological mechanisms that affect appetite and satiety in the assessment of DEB in patients with diabetes may also be clinically relevant.

CLASSIFICATION: ADHERENCE NONCOMPLIANCE, OR DISTRESS

Behaviors considered triggers and consequences of DEB are embedded in the diabetes treatment regimen (49). Behaviors and attitudes such as dietary restraint, food preoccupation (carbohydrate monitoring and restriction, portion control, and control of blood sugars through selective food intake), and programmed exercise are prescribed components of diabetes care (39,50). These same behaviors, excepting control of blood glucose, characterize successful weight loss treatment (51). Behaviors become dysfunctional, DEB or eating disorders, when they are used inappropriately for rapid weight loss, are carried to excess, interfere with activities of daily living, or become a health risk (33). However, in the context of diabetes care, strict adherence to these behaviors provides tools by which glycemic control may be achieved (39). Thus, endorsement of items on screening measures such as the EAT-26, EDI-III, and Diagnostic Survey for Eating Disorders (52) indicating food preoccupation and restriction could initially be identified as DEB in patients with diabetes. When using measures standardized in the general population, clinical evaluation by an individual familiar with the diabetes self-care regimen may be needed to further elucidate the intent and relationships between endorsed behaviors and weight concerns.

Feeling out of control of food intake is a DSM-IV-TR diagnostic criterion for bulimia, BED, and EDNOS (see Table 1: DSM-IV-TR criteria) (33). Attempts to follow a prescribed dietary plan have been documented to result in patients experiencing loss of control of eating behavior (53). The essential criterion for BED is repeatedly eating amounts of food in a short period of time that are “larger than most individuals would eat under similar circumstances.” Because DEB is rarely quantified by direct observation, this criterion is usually self-reported. The determination of an objective versus a subjective binge is an established challenge in the evaluation of eating disorders. Illustrating the relationship between report of food intake, weight status, and diabetes, a study of black women with type 2 diabetes found the prevalence of underreporting of dietary intake to be 47%. Underreporting of intake was significantly associated with BMI and waist circumference in the expected direction: larger body size (54). Thus, overweight patients with type 2 diabetes may underreport dietary intake. Studies that evaluated whether type 1 diabetic patients overreport or underreport dietary intake associated with their weight status could not be identified using our search strategies.

Table 1

Adapted from the DSM-IV-TR: necessary diagnostic criteria for eating disorders (axis-1)

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 <85% of that expected or failure to make expected weight gain during period of growth, leading to body weight <85% of that expected).
    Intense fear of gaining weight or becoming fat, despite being underweight.
    Disturbance in the way in which one'' needs and opinions before one''m not even hungry” are BULIT-R questions (used in studies by Affenito et al. [17,18]) that directly relate to the diabetes care regimen: the former by prescription of dietary restraint and the latter by use of exogenous insulin. A later question, “I feel that food controls my life,” could be endorsed by any individual with diabetes. Similarly, questions on the EDI-3 Drive for Thinness Scale include, “I eat sweets and carbohydrates without feeling nervous,” and “I feel extremely guilty after overeating.” Three of seven questions on the Drive for Thinness subscale (used by Engstrom et al. [19] to evaluate females, and Svensson et al., [34] to evaluate males) of the EDI regarding eating and dieting that could be answered in the context of having and treating diabetes were identified. An additional three that address the importance of weight status could potentially be endorsed in the context of health care provider recommendations. Using EDI-3 adult and adolescent norms, endorsement of these questions would likely meet criteria for the presence of subclinical DEB. Similarly, the DSED (used by Rydall et al., [15] and Jones et al., [29]) asks about dieting behaviors that could be treatment based. Thus, when using questionnaires standardized in healthy populations, scores may be elevated in both type 1 and type 2 diabetic patients due to items that reflect the diabetes self-care regimen. Conversely, patients who are hesitant to reveal treatment-related weight concerns to health care providers may under-endorse items that relate to their regimen. It has been suggested that refinement of questions and criteria to include the effects of diabetes treatment is needed (49).

Intentional omission or reduction of insulin dose for weight management purposes is included in DSM-IV-TR criteria (see Table 1) under the category of purging behavior (27). However, this behavior could be an aspect of generalized noncompliance (12) or an attempt to reduce hunger, improve feelings of satiety, or reduce the cycle of overeating consequent to hypoglycemia. If the question is posed whether insulin omission is intended to control weight, the answer is frequently affirmative (6,8,10). Further refinement of the question querying the intent of and motivation for insulin reduction in the context of insulin dosing and hunger, as well as weight concerns, would help to establish whether the behavior could be considered adaptive rather than a purge of calories via glycosuria (10). The EDE asks after behavioral intent, associated mood, and thoughts. However, the contribution of the diabetes care regimen, diabetes self-management education, and health care provider directives regarding weight are not routinely assessed to determine their contribution to weight-driven behaviors or concerns. Further refinement and standardization of questionnaires and interview formats to determine the motivation and intent of behaviors in the diabetes population will increase diagnostic accuracy in the context of diabetes.

The Diabetes Eating Problems Survey (DEPS), created by Markowitz et al. (62), includes questions regarding insulin adjustment specifically for the purposes of weight reduction and couches questions in terms of diabetes care. Issues related to glycemic control and iatrogenic weight gain are specifically identified and questioned. A questionnaire that asks about satiety and fullness in the context of insulin dosing, blood glucose levels, and eating in response to hypoglycemia is currently for 1 last update 08 Jul 2020 being tested and standardized (D.L.Y.-H. and C.L.D., personal communication). Validity studies that compare the use of well-established DEB criteria, interview formats, and instruments, versus diabetes-specific questionnaires and interview formats assessing treatment prescription, adjustment to illness, hunger, satiety, and unintended outcomes of treatment, are suggested to enhance the accuracy of diagnosis and prevalence of eating disorders and DEB in this population.The Diabetes Eating Problems Survey (DEPS), created by Markowitz et al. (62), includes questions regarding insulin adjustment specifically for the purposes of weight reduction and couches questions in terms of diabetes care. Issues related to glycemic control and iatrogenic weight gain are specifically identified and questioned. A questionnaire that asks about satiety and fullness in the context of insulin dosing, blood glucose levels, and eating in response to hypoglycemia is currently being tested and standardized (D.L.Y.-H. and C.L.D., personal communication). Validity studies that compare the use of well-established DEB criteria, interview formats, and instruments, versus diabetes-specific questionnaires and interview formats assessing treatment prescription, adjustment to illness, hunger, satiety, and unintended outcomes of treatment, are suggested to enhance the accuracy of diagnosis and prevalence of eating disorders and DEB in this population.

SUMMARY

Limitations of current research findings

Gaps in understanding the association of DEB and diabetes include: lack of weight-matched control subjects when comparing the prevalence of eating disorders or subclinical DEB; evaluation of the contributions of an insulin dosing schedule and overinsulinization (19), loss of satiety mechanisms via hormonal dysregulation, and dietary prescriptions as potential causes perceived as loss of control over food intake; the intent of behavior in those seeking to prevent weight gain secondary to treatment; incomplete psychological characterization of samples, including psychological constructs such as loss of control, autonomy, and self-efficacy over blood glucose and weight; the potential for misclassification of behaviors and attitudes as reflecting DEB when they possibly reflect skills and attitudes learned as part of the diabetes care/self-management regimen; and the need for refinement of existing measurement tools and development of assessment methods that address diabetes-specific attitudes, concerns, and behaviors that are prescribed as part of treatment; as well as physiological mechanisms that are beyond the control of the patient.

Most studied cohorts have consisted of subjects that were white, heavier than control samples, recruited from tertiary care centers, and often monitored more frequently and thoroughly than patients receiving care in the community. Sample selection bias may be operating to eliminate well-controlled well-adjusted individuals from clinical studies, potentially selecting individuals most vulnerable to the development of DEB. No studies were identified that monitored patients from the time of diagnosis to establish the temporal sequence of the onset of behavior considered maladaptive and whether weight gain occurs first or the care regimen is manipulated to prevent weight gain. Few studies could be found wherein the comorbidity of depression and other forms of psychological distress and DEB were evaluated.

Directions for future research

Evaluation, characterization, and classification of DEB in individuals with diabetes have clinical importance. However, classification of these behaviors is less clinically informative if population-specific criteria and taxonomy are not established. Further, focusing on identified gaps in future investigations of DEB in this population could improve clinical care for this serious comorbid condition. Studies that chronicle the development of DEB prospectively from diagnosis will allow us to assess the contributions of the many factors that predispose individuals to the development of DEB, potentially identifying approaches to diabetes treatment with a lower risk of iatrogenic complications. It is clinically important to be able to identify those individuals who are at risk for this comorbid condition in association with and independent of the burden of diabetes care. In order to distinguish whether insulin reduction or omission is maladaptive, evaluation of the intent and context of this behavior is needed. Is it a means to regain control over excessive eating by using self-management skills or, in contrast, is it intended as a short-cut weight management strategy (purging via glycosuria)? Physiological mechanisms such as an insulin dose in excess of physiological requirement, hypoglycemia, and a hormonally driven imbalance in hunger, food intake, and experience of satiety appear to be critical factors in establishing diabetes-specific criteria that discriminate between maladaptive manipulations of the diabetes care regimen to control weight and potentially adaptive regimen modifications. Studies are needed that address these distinctions.

Acknowledgments

No potential conflicts of interest relevant to this article were reported.

Rachel Segall is thanked for her willingness to explain the symptoms associated with out-of-control eating and weight gain, while maintaining excellent overall control of her diabetes. She, among others with diabetes, is to be applauded for her tenacity and willingness to question the diabetes care regimen and allowing health care providers to know when the regimen isn''Neil PM, Sebastian SB, Barker SE: Prevalence of binge eating disorder in obese adults seeking weight loss treatment. Eat Weight Disord 1997;2:117–124 [PubMed] [Google Scholar]

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