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Eating Disorders in Children and Teens with Type 1 Diabetes 1984-ongoing

Eating Disorders in Children and Teens with Type 1 Diabetes 1984-ongoing. Denis Daneman University of Toronto And The Hospital for Sick Children. ED Classification. Clinical/full-blown: DSM-lV: Anorexia nervosa Bulimia nervosa Eating Disorder Not Otherwise Specified (EDNOS)

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Eating Disorders in Children and Teens with Type 1 Diabetes 1984-ongoing

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  1. Eating Disorders in Children and Teens with Type 1 Diabetes 1984-ongoing Denis Daneman University of Toronto And The Hospital for Sick Children

  2. ED Classification • Clinical/full-blown: DSM-lV: • Anorexia nervosa • Bulimia nervosa • Eating Disorder Not Otherwise Specified (EDNOS) • Subthreshold (not subclinical) • Disturbed Eating Behavior that does not meet criteria for full-blown ED, but with clinical consequences (e.g. A1c, complications)

  3. Working Model: Rodin & Daneman 1992 Individual, family, and societal factors Diabetes-specific vulnerabilities: Insulin-related weight gain Nutritional counseling Poor self-esteem Eating Disorders: Core Features: Body dissatisfaction Drive for thinness Dietary restraint Disordered eating attitudes and behavior: Insulin omission Binge eating Dieting Diabetes-specific outcomes: Poor metabolic control: high HbA1c Microvascular complications, e.g., retinopathy

  4. Predictions arising from our model: • Prevalence • Natural history • Associated with • poorer control • specific behavior, especially insulin omission • early complications • specific family issues • Difficult to treat

  5. DM: 356 DSM-IV: 36 (10%) AN 0 (0) BN 5 (1.4) NOS 31 (8.7) Controls: 1098 (3:1) 49 (4%) <.001 0 (0) NS 5 (0.5) NS 44 (4.0) <.001 OR = 2.4 (1.5-3.7) Jones et al, BMJ 2000: DSM-IV diagnosable ED

  6. DM: 356 49 (14%) DSM-IV + ST 85 (24%) Controls: 1098 84 (8%) <.001 OR = 1.9 (1.3-2.8) 134 (12%) OR = 2 Jones et al, 2000: Subthreshold Disorders:

  7. Obstacles identified during initial assessment

  8. HbA1c by Disordered Eating Status at Baseline and Follow-up. HbA1c (%) *HbA1c for the highly disordered group was significantly higher than the moderately and non-disordered groups at baseline, p<.001; **HbA1c for the highly and moderately disordered groups was significantly higher than the non-disordered group at follow-up, p<.005 (Rydall et al., 1997).

  9. Common behaviors in girls with type 1 diabetes. Percentage of Sample Binge eating *Dieting **Insulin omission ***Self- induced vomiting Laxative use McNemar’s test for change in prevalence, baseline to follow-up: *p=0.01; **p=0.003; ***p=.06 (Rydall et al., 1997).

  10. Age and Prevalence of Insulin Omission for Weight Control. Insulin Omission Prevalence of Insulin Omission (%) 12-18 years 16-22 years 9-13 years 1Colton et al., 2000 (n=90): 1% prevalence of insulin omission in pre-teen girls; 2 Rydall et al., 1997 (n=91): 14% in adolescent girls (baseline assessment); 3 Rydall et al., 1997 (n=91): 34% in young adult women (four-year follow-up of baseline sample).

  11. Evolution of ED in teen girls with T1D • In progress, study of natural history of ED in girls with T1D; • Baseline: 101 9-13.9 yo with T1D & 303 controls • Follow-up of DM cohort for 5-8 years • Demographics at Baseline: • Mean age 11.8 years • Mean A1c 8.2% • Mean duration of T1D 4.7 years

  12. DISTURBED EATING BEHAVIOUR(last month) * *

  13. EATING DISORDERS: T1D VS. SCHOOL GIRLS % sample p = .001 • No sign differences in: • Age • A1c • Duration of T1D • Those with ED BMI > • those without

  14. FIVE-YEAR FOLLOW-UP • 13.3% of participants (13/98) met criteria for an ED • 3 girls had bulimia nervosa • 3 had ED-NOS • 7 had a subthreshold ED • 44.9% of participants were classified as overweight or obese

  15. FIVE-YEAR FOLLOW-UP • A1c not higher in girls with DEB • (8.7% vs. 8.4%; p = 0.11) • Trend for higher A1c in those with an ED • (9.1% vs. 8.5%; p = 0.08) • BMI higher in those with DEB • (26.1 versus 23.5; p = 0.001)

  16. ED POINT PREVALENCE & CUMULATIVE PREVALENCE BY AGE

  17. FIVE-YEAR FOLLOW-UP • Higher BMI and DEB were strongly associated, which presents a management dilemma • Both dietary restraint and higher weight are risk factors for the development of ED and their negative health consequences

  18. PREDICTION OF THE ONSET OF DISTURBED EATING BEHAVIOUR IN ADOLESCENT GIRLS WITH TYPE 1 DIABETES

  19. LOGISTIC REGRESSION MODEL WITH BACKWARD STEPWISE REGRESSION Dietary Restraint Weight & Shape Concern Physical Appearance Self-Worth Depression X2 = 43.254, df = 5, p<.0001 McFadden’s R2 = 0.416

  20. If the model is correct, then the prevalence of complications should be more common in ED: Percentage of Sample MicroAlbuminuria (Rydall et al., NEJM 1997).

  21. Is family dysfunction more common in ED than nonED DM: • To investigate if and how eating disturbances in girls with type 1 DM are associated with: • Mother’s weight and shape concerns • Mother-daughter relationships • Adolescent self-concept

  22. TEENS (N=88) Age = 14.9 yrs. (+ 2.2) Weight = 58.9 kg (+12.7) BMI = 22.4 kg/m2(+3.7) Age of Diabetes Onset = 7.9 yrs (+ 4.0) Illness Duration = 7.1yrs (+3.9) HbA1c = 8.9 % (+ 1.6) MOTHERS (N=88) Age = 43.7 yrs (+ 5.5) Weight = 69.3 (+13.7) BMI = 25.9 (+4.9) Middle Class Completed 1-2 years of college, university, or specialized training Method

  23. Multivariate Group effect [F(6, 160 ) = 3.97, p =.001] Highly & Mildly Disturbed girls report more impaired relations with mothers on all dimensions compared to Non-Disturbed girls (p = .01) Perceived Relationships With Mothers Communic. Trust Alienation

  24. Mother’s Eating and Weight Loss Behaviors • Multivariate Group effect [F (10, 138) = 2.12, p = .03] • Mothers of Highly & Mildly Disturbed girls are more weight dissatisfied (p = .01) and are more likely to exercise for weight control (p = .02), diet (p = .05), and binge eat (p = .02). Satisfaction Diet Exercise Binge

  25. Prevention and Treatment in DM and ED: • Prevention: not reported • Treatment: • CBT - Peveler and Fairburn 1989 • Fluoxetine - case report - 1990 • Psychoeducation - Olmsted 2000

  26. Evidence-based conclusions:Model validation • Eating disorders are more common in adolescent and young adult females with diabetes (Level 1) • When present they are associated with • high frequency of insulin omission (Level 1) • worse metabolic control (Level 2) • earlier onset of complications (Level 1) • family dysfunction (Level 2) • They are (more) difficult to treat (Level 4)

  27. Approach to ED in DM • Awareness of the association • Ask the “right” questions • If suspect “fullblown” ED - refer • If subthreshold - clinic-based intervention • Complication surveillance

  28. Asking the “right” questions • “Red flags” • Dealing with reluctance to disclose • Their stories… • Partnering with patients • Regaining control • Treatment options

  29. Red Flags • Persistently high A1c • Frequent DKA, illnesses • Distress re: weight • Widely fluctuating b.g.s • Skipping meals • “Binging”; feeling hungry all the time • Skipping dosing/underdosing

  30. Initial response to high A1c: • Raise the dose • Labeled “insulin resistent” • Problem: “insulin avoidant”

  31. Disclosure is very difficult • Shame • Feel like “failures” • Failed: • Their families • Their providers • Themselves • Important to be nonjudgemental and supportive

  32. In their words….

  33. A start…. • Information can be helpful • “Unfortunately something many young people struggle with…” • Insulin omission drives hunger • Losing control over eating behavior • Information for parents • Families are angry, blaming • They feel like failures too

  34. Regaining control • A step at a time • Steps forward, steps back • Treatment options: • Partner with existing ED programs • Requires collaboration • Groups • Conventional treatment • Medication/Consult

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