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Women, Diabetes, and Disordered Eating

Michele D. Levine, MS, and Marsha D. Marcus, PhD

Over the past 20 years, research on the nature, assessment, and treatment of eating disorders has flourished. As knowledge has grown, researchers and clinicians have become increasingly aware of a possible relationship between eating disorders and diabetes. Since eating disorder symptoms, such as concerns about body shape and weight and the misuse of food and dieting, are widespread among women, it is not surprising that these attitudes and behaviors are also important health issues for women with diabetes. Moreover, some have argued that diabetes-specific factors, such as the need to carefully monitor eating, exercise, and insulin treatment, may contribute to the development of eating disorder symptoms. In this report, we will provide some general information about eating disorders and the prevalence of eating disorders and their symptoms among women with diabetes. We will then focus on issues related to the management of eating concerns for women with diabetes.

Eating Disorders: Diagnosis and Assessment
The fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV)¹ defines three eating disorders: anorexia nervosa (AN), bulimia nervosa (BN), and eating disorder not otherwise specified (EDNOS). Binge eating disorder (BED), is included in the DSM-IV as a specific instance of EDNOS that has received much recent attention. The essential characteristics of AN are a refusal to maintain a minimal normal body weight, amenorrhea, a fear of gaining weight, and a distorted perception of body shape and weight. BN is characterized by frequent and recurrent episodes of binge eating and the use of inappropriate compensatory behaviors (e.g., vomiting, laxative abuse, fasting, or vigorous exercise) to prevent weight gain. Individuals with BN also have a self-concept that is overly influenced by body shape and weight. Similar to women with BN, those with BED engage in frequent and recurrent episodes of binge eating. However, in BED the binge eating occurs in the absence of regular compensatory behaviors. Binge eating, then, is a distinguishing behavior of both BN and BED and refers to the consumption of a large amount of food (more than most people would eat given the circumstances) in a specified period of time.

The most reliable way to establish an eating disorder diagnosis is through a structured clinical interview, such as the Eating Disorder Examination (EDE).² Because the structured interview format of the EDE provides precise operational definitions for the classification of binge eating episodes and allows clinicians to assess insulin misuse directly, it may be a useful tool for establishing eating disorder diagnoses in women with diabetes.

A number of self-report assessments of eating disorder symptomatology also may be useful to clinicians working with women with diabetes. Two common, standardized eating disorder questionnaires are the Eating Attitudes Test³ and the Eating Disorders Inventory.⁴ Both provide assessments of the attitudes and behaviors associated with eating disorders and have been widely used in nonclinical populations. (Please see note at the end of the article for information on how to obtain copies of the EAT and EDI.) One caution, however, when using these self-report instruments is that some of the questions in the EDI and EAT ask about behaviors that are appropriate, expected aspects of diabetes management (e.g., avoiding sweets, monitoring food intake). Several investigators have removed these questions to provide more accurate comparisons between women with and without diabetes.^5,6

It is estimated that between 0.5 and 2% of young adult women have an eating disorder.^7,8 Both AN and BN are far more common among females than males, although the occurrence of eating disorders in men has been a subject of recent attention.⁹ Full syndrome cases of eating disorders are not common. However, the symptoms of disordered eating, such as concerns about shape and weight, the misuse of food, and inappropriate dieting behaviors are quite prevalent among women. Indeed, as many as 19% of young adult women suffer from subclinical binge eating problems.⁷ Moreover, although disordered eating behaviors may be somewhat more common among younger women, they are not specific to adolescent and young-adult age-groups. Women of all ages in our society endorse concerns about weight and eating.¹⁰ Because of the pervasiveness of dieting and weight concerns among women, and because disordered eating may have unique manifestations and consequences in women with diabetes, it is important to examine the particular risk factors for and consequences of disordered eating behaviors in women with diabetes.

Disordered Eating and Diabetes
Standard diabetes treatment necessitates a focus on dietary intake and exercise habits. The focus on weight, eating, and exercise itself may place women with type 1 diabetes at risk for developing unhealthy concerns about body shape and weight and/or inappropriate eating and dieting behaviors. Additionally, type 1 diabetes typically is diagnosed in pre-adolescent children, and an individual's attitudes about shape and weight have been shown to become more disturbed during the year following the diagnosis of diabetes.¹¹ Because fears about gaining weight, concerns about body shape, and an increased sensitivity to diet are risk factors for disordered eating, particularly during puberty,^12,13 there has been substantial concern that young women with type 1 diabetes would be more likely than their peers to struggle with disordered eating.¹⁴

Moreover, the potential to misuse insulin in an effort to control shape and weight provides women with diabetes on insulin therapy a unique form of compensatory behavior. A patient may decrease her insulin dose to promote the spilling of calories, or she may omit a dose completely. An individual on a flexible dosing schedule may also intentionally fail to increase her standard dosage to account for an episode of binge eating to avoid weight gain. Thus, there are a number of aspects specific to the diabetes regimen that may contribute to the development and maintenance of eating disorder behaviors in women.

To date, only a few well-controlled studies have compared the rates of eating disorder diagnoses between women with and without diabetes.^15-17 The results in each study have indicated that, despite the unique risk factors, women with type 1 diabetes are not more likely than their nondiabetic peers to be diagnosed with an eating disorder. That the rate of eating disorder diagnoses does not differ between women with and without type 1 diabetes is not surprising given the low base rate of clinical eating disorder diagnoses.^7,8 Despite the low prevalence rate of full syndrome eating disorders in women with and without diabetes, subthreshold eating problems may pose particular problems for women with diabetes.

Substantial data have confirmed that the prevalence of eating disorder symptomatology among women with diabetes is alarming. Women with diabetes exhibit higher levels of eating disorder attitudes and behaviors in comparison to their nondiabetic peers.^5,6,18 For example, Neumark-Sztainer and her colleagues¹⁸ found that 27% of adolescent girls with type 1 diabetes reported purging, and 24% reported dieting to lose weight, whereas only 9% and 14% of teenage girls without diabetes reported engaging in these behaviors. The elevated level of eating disorder symptoms is higher in young females with type 1 diabetes than in males, regardless of differences in body weight between the genders.¹⁹

As mentioned previously, the misuse of insulin by failing to account for episodes of overeating or by underdosing to effect weight loss is an eating disordered behavior specific to women with diabetes. Women who neglect insulin doses either to promote weight loss or for other reasons are more distressed about their eating, endorse greater overall psychiatric distress, and have more discomfort about aspects of their diabetes management than do those women who do not miss doses of insulin.²⁰ More importantly, women who report omitting insulin for the specific purpose of controlling their weight or compensating for episodes of overeating report higher levels of eating disorder symptomatology, have more psychiatric symptoms and diabetes-specific distress, and are more likely to have a history of AN or BN.^20,21 Individuals who misuse insulin because of weight concerns also omit insulin more frequently and are, in general, less adherent to other aspects of their diabetes management than are those who skip insulin doses for reasons not related to weight control²⁰ or do not misuse insulin at all.²¹

Although the presence of disordered eating behaviors among young women with type 1 diabetes is disturbing, it is important to reiterate that many of these behaviors are also common among women who do not have type 1 diabetes. In the study mentioned previously,¹⁸ 35% of the teens with diabetes reported binge eating compared to 25% of control subjects. Similarly, patients with type 2 diabetes do not report significantly more binge eating than age- and weight-matched control subjects.²² Thus, women with diabetes appear to have higher rates of compensatory behaviors (i.e., purging, insulin misuse, extreme dieting), but the general misuse of food and binge eating are common among women both with and without diabetes.

Eating Disorders and Diabetes Across the Lifespan
It is interesting to note that insulin manipulation occurs in women of all ages. In their study, Polonsky and colleagues²⁰ sampled women who were, on average, 33 years old and found that approximately one-third of them reported intentionally manipulating their insulin. The majority of women who acknowledged misusing insulin reported only occasionally taking less insulin. However, among women in late adolescence, intentional insulin omission was a more frequent occurrence. Younger patients with diabetes are also more likely to require treatment for ketoacidosis as a result of their insulin misuse.²³

One hypothesis that may be suggested to explain the coexistence of eating disorder symptoms and behaviors in younger women with diabetes is that adolescence is a period of greater risk-taking. Thus, teenagers with diabetes may be experimenting with levels of unhealthy behaviors that are normative for their peer group. Adolescents are less adherent to their diabetes regimen than are younger children,²⁴ and teens with diabetes may be apt to participate in a wider range of unhealthy behaviors than are older women. Fortunately, although adolescents with type 1 diabetes do engage in risky behaviors (e.g., cigarette smoking, alcohol use), they do not appear to participate in these activities more frequently than their nondiabetic peers.²⁵ It is also possible that the overlap of disordered eating and diabetes in younger women is related to the worsening of eating disorder attitudes, such as a desire to be thin or a dissatisfaction with body shape, during the year following the onset of diabetes treatment.¹¹

Consequences of Eating Disorder Symptoms for Women With Diabetes
A variety of serious medical complications are associated with disordered eating. In individuals with AN, the complications are primarily the result of the self-imposed starvation and include symptoms such as lethargy, cold intolerance, dehydration, and heart problems. The complications of BN are typically associated with purging behaviors and include electrolyte abnormalities, the destruction of dental enamel, and esophageal tears. Although these consequences alone are serious, eating disorder behaviors may present even more severe health risks for women with diabetes for a number of reasons.

First, the relationship between subclinical eating disturbances and poor metabolic control has been well established. The frequency of binge eating has been linked to measures of poor metabolic control, and women with both clinical and subclinical eating disorders have more diabetes-related medical consequences than do women with diabetes who are free of disordered eating.^26,27 Disordered attitudes about eating, as well as specific eating disorder behaviors, have been associated with poorer glycemic control.²⁸

Second, the consequences of disordered eating may be particularly severe among the subgroup of women who misuse insulin for the purpose of avoiding weight gain because, in addition to employing drastic measures of weight control, these women are also more likely to be noncompliant with all aspects of their diabetes prescription and overall self-care.^21,27,29 In addition, the medical complications of disordered eating may be compounded by additional psychiatric disorders. Eating problems in women with type 1 diabetes are associated with a higher level of overall distress,²⁰ and young children with type 1 diabetes who have problems related to their eating are more likely to develop other psychiatric disorders than are their same-age peers who do not have eating problems.²⁹

Thus, despite similarity in the rates of clinically determined eating disorder diagnoses in women with and without diabetes, subclinical levels of eating disorder symptomatology in women with diabetes may lead to long-term medical complications. In addition, subclinical levels of eating disorder symptomatology may, if untreated, progress to more serious, health-threatening levels of disordered eating. It is, therefore, critical to address any mild disturbance in eating behaviors and attitudes to prevent the development of a full-blown eating disorder.

Treating Eating Disorder Symptoms in Women With Diabetes
Unfortunately, there have been few studies concerning the specific treatment of an eating disorder in women with diabetes. Currently, the best-studied treatment for disordered eating, and for binge eating in particular, is cognitive behavior therapy (CBT),^30,31 and one study³² has examined CBT in women with both type 1 diabetes and an eating disorder. In this study, CBT was effective in changing the eating habits and improving the glycemic control of women with diabetes and an eating disorder. However, the authors noted that the treatment of the eating problem was more difficult in women with both type 1 diabetes and an eating disorder. Recent research has also indicated that interpersonal psychotherapy (IPT) may be effective for women with an eating disorder.³³ However, the usefulness of IPT for women with type 1 diabetes has yet to be explored. Further research on the utility and acceptability of both IPT and CBT for women with diabetes struggling with an eating disorder is certainly warranted.

Antidepressant medication is often used in conjunction with psychotherapy in the treatment of disordered eating. Selective serotonin reuptake inhibitors (SSRIs), for example, have been shown to be moderately effective in reducing binge eating and purging among women with BN.³⁴ Anti-depressant medications, in particular SSRIs, also have been used to treat obesity.^35,36 Because the relationship between type 2 diabetes and obesity has been well established, pharmacological treatment for weight loss has special relevance for the treatment of type 2 diabetes. Specifically, weight reduction has long been recognized as an important aspect of treatment for obese patients with diabetes, and antidepressant treatment has been shown to result in modest weight loss and decreases in insulin dose among obese individuals with diabetes.³⁷ Recent evidence suggests that fluoxetine, an SSRI, also improves insulin sensitivity independent of its anorectic properties,³⁸ although the primary mechanism behind this increased sensitivity is unknown.

To summarize, both psychotherapy and antidepressant medication are moderately effective treatments for disordered eating. Women with type 1 diabetes and eating problems are likely to benefit from a combination of psychotherapy and antidepressant treatment in dealing with binge eating and related eating disorder symptoms. Research showing that SSRIs not only promote weight reduction, but also improve insulin sensitivity suggests that this form of pharmacotherapy may be useful for overweight women with type 2 diabetes. Moreover, for overweight women with BED, antidepressant therapy offers the additional benefit of helping to ameliorate binge eating and related eating disorder symptomatology.

Finally, results from the Diabetes Control and Complications Trial (DCCT) may have implications for the management of diabetes in women with eating disorder symptoms. The DCCT demonstrated the benefits of an intensive insulin regimen in delaying the onset and slowing progression of the long-term microvascular and neurological complications of diabetes.³⁹ Because an intensive insulin regimen is associated with weight gain,⁴⁰ and women are likely to endorse the potential for weight gain as a concern with intensive treatment,⁴¹ clinicians need to attend to these concerns about shape and weight. A young woman with weight and eating concerns, for instance, may not be willing to tolerate the substantial commitment to her diabetes care necessary with intensive insulin therapy, and some clinicians⁴² have suggested that eating disorders and other psychological illnesses may contraindicate use of intensive insulin therapy. Thus, women's concerns about shape and weight require assessment and discussion before the initiation of intensive insulin therapy. The diabetes team may then be able to intervene with education and commitment strategies to increase compliance with the intensive regimen.

In summary, despite initial speculation, diagnosable eating disorders are no more common in women with diabetes than in those without. Eating disorder symptoms are common among all women. However, evidence suggests that subclinical eating disorder attitudes and behaviors may be even more prevalent among women with diabetes.

Because disordered eating is associated with more critical health risks in women with diabetes than in those without, the prevalence of these symptoms is a source of serious concern. Specifically, binge eating and the manipulation of insulin affect glycemic control. Therefore, it is important that clinicians working with women with diabetes be mindful of eating disorder symptoms.

It is advisable for clinicians to routinely inquire about episodes of overeating, insulin misuse, and concerns about body shape and weight, and to create a therapeutic context in which such problems can be discussed. In other words, clinicians who work with women with diabetes must strive to balance the strict promotion of healthy behavior with an acceptance of women's concerns about body shape and weight. Women with significant concerns or symptoms should be referred to a mental health professional, preferably one with experience treating disordered eating.

References

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Michele D. Levine, MS, is a doctoral candidate in clinical psychology at the University of Pittsburgh and Western Psychiatric Institute and Clinic in Pittsburgh, Pa. Marsha D. Marcus, PhD, is an associate professor of psychiatry and psychology and director of the Outpatient Eating Disorder Clinical at Western Psychiatric Institute and Clinic.

Acknowledgment: This work was supported by grant RO1 DK 36452 from the National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, and by a Clinical Research Grant from the American Diabetes Association.

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