Aetiology of eating disorders
Risk factors for the development of an eating disorder include being female, being overweight or gaining weight, dietary restraint, early puberty, low self-esteem, disturbed family functioning, peer and cultural influences, personality traits and gene-environment interactions. Several of these factors may be associated with the diagnosis or management of type 1 diabetes. While the evidence that disordered eating and eating disorders are more common in individuals with type 1 diabetes is not conclusive, examination of some of the risk factors for disordered eating in the context of diabetes shows why an increased prevalence might occur.
An Etiological Model of Eating Disorders [Click to enlarge]Monitoring and attention to the nutritional composition of food, cognitive control of food intake and potentially limiting type or quantity of food are elements of dietary restraint that are frequently involved in managing type 1 diabetes. Most of the research on dietary restraint has related to restraint for the purpose of weight loss, but the side effects of dietary restraint may be experienced without this goal. Dietary restraint is associated with preoccupation with food, weight fluctuation, binge eating, psychological deprivation and depression. When food intake is brought under cognitive control, instead of relying on physiological cues related to hunger and satiety, certain conditions can reliably undermine this control. These include emotional upset or anxiety, the consumption of alcohol, and exposure to food cues such as the sight or smell of appealing food. Cognitive and emotional effects of dietary restraint involve an increased focus on food and weight information, and being more easily distracted and emotionally labile. See McFarlane, Polivy and McCabe (1999) for a comprehensive review. These consequences of dietary restraint make it more difficult to adhere to a cognitively determined eating plan. Unfortunately deviations are likely to be experienced as failures, and if the remedial action is a heightened emphasis on “willpower” and cognitive control, additional deviations are even more likely. A self-perpetuating cycle of episodes of failed dietary restraint followed by increased effort to diet followed by increased episodes of failure may have a very significant impact on self-esteem, especially in the context of the current cultural message that success at controlling food intake is evidence of willpower and other valued character traits. This cycle can also predispose to developing more dysregulated eating patterns, including more extreme fasting as well as episodes of uncontrolled eating i.e., binge-eating.
Overweight or weight gain
Overweight and perceived overweight are risk factors for disordered eating because they may trigger dieting, weight preoccupation and body image disparagement. Individuals with type 1 diabetes are, on average, heavier than their peers, and additionally, better diabetic control is associated with higher stable weight . Conflict between the goals of weight reduction and optimal diabetic control may auger an emotionally charged relationship with the body and a focus on its apparent shortcomings.
Low self-esteem, and depression
For individuals with type 1 diabetes, adherence to dietary guidelines and control of blood glucose levels may be aspects of performance that particularly lend themselves to evaluation, and indeed these central aspects of diabetes management are regularly evaluated and reinforced by health care providers and family members. Concerns about weight or the health consequences of sub-optimal diabetic control may increase the emotional value of success in these areas, and shortcomings may be viewed as significant personal failures. Management of diabetes provides multiple opportunities each day for feedback about performance, and for some individuals, especially those with a perfectionist temperament, this may be experienced as repeated and relentless evidence of failure. Self-evaluation and self-esteem may become linked to control of eating and management of blood glucose levels. This link is considered to be an important risk factor for the development of an eating disorder. In some cases the conflict between a goal of weight loss and a goal of good diabetic control leads to a no-win situation in which the individual always feels like a failure with respect to one or the other objective.
Disturbed family and interpersonal functioning
Management of a chronic condition creates extra demands on the family, and can provide an additional source of stress and distress. When an adolescent or young adult woman has poor diabetic control, her eating and management regimen may be closely scrutinized by family members and health care providers. Her performance and her failure experiences may be very public. Others may respond with high anxiety, high emotion and strategies such as providing information, lecturing or scare tactics intended to promote better performance. If these strategies are ineffective, family members and care providers may feel frustrated and frightened and may become activated and unhelpful. As interpersonal tension increases, the individual with diabetes is left with more stress and negative feedback and a loss of support that others might provide.
The adolescent process of negotiating autonomy is more complicated when parents are frightened about their child’s health and well-being. Eating and diabetes management can become the arena for power struggles. While a version of this dynamic may contribute to the development of eating disorders in adolescents who do not have type 1 diabetes, the increased risk for and severity of negative health outcomes and the persistent feedback about performance related to diabetes management may intensify the situation and increase the risk for development of disordered eating in young women with type 1 diabetes.
Aspects of Diabetes Care that May Facilitate an Eating Disorder
Insulin under-dosing or omission
Insulin omission provides a readily available, easy and discreet method of wasting calories. These features may make this an appealing method of weight control. As with other methods of purging calories, once this behavior is conceptualized as an option the individual may feel less pressure to avoid overeating or binge eating.
Some individuals with type 1 diabetes have difficulty following the protocol for treating hypoglycaemia and eat more than is recommended. This is frequently the case in those who are already struggling with dysregulated eating. Eating at this time may be viewed as a way to increase blood glucose and feel better faster, may help reduce feelings of panic or worry, or may serve as a distraction. Overeating may become a method of calming oneself, and this can extend to other situations. In some cases individuals with type 1 diabetes have full blown eating binges that are triggered by hypoglycemic episodes. Concern about weight gain, following overeating or binge eating, is likely to lead to compensatory behavior such as insulin omission or food restriction, which in turn contributes to a cycle of dysregulated eating.
References and Additional Reading
Colton, P., Olmsted, M.P., Daneman, D. & Rodin, G. Depression, disturbed eating behaviour and metabolic control in teenage girls with type 1 diabetes. Pediatric Diabetes, 2013, 14, 372-376.
Colton, P.A., Olmsted, M.P., Daneman, D., Rydall, A.C. & Rodin G.M. Natural history and predictors of eating disturbances in girls with type 1 diabetes mellitus. Diabetic Medicine, 2007, 24, 424-429.
Colton P, Rodin G, Bergenstal R, Parkin C. Eating disorders and diabetes: introduction and overview. Diabetes Spectrum, 2009; 22, 138-142.
Colton, P.A., Rodin, G.M., Olmsted, M.P. and Daneman, D. Preventing eating disorders in young women with diabetes. In Piran, M.P. Levin & C. Steiner-Adair. Brunner/Mazel, (Eds.), Preventing Eating Disorders: A Handbook on Interventions and Special Challenges. Philadelphia, PA: 1999.
Daneman,D., Rodin., G. Jones, J. Colton, P. Rydall, A., Maharaj, S. and Olmsted, M.P. Eating disorders in adolescent girls and young adult women with type 1 diabetes. Diabetes Spectrum, 2002, 15, 83-105.
The DCCT Research Group: Influence of intensive diabetes treatment on body weight and composition of adults with Type 1 diabetes in the Diabetes Control and Complications Trial. Diabetes Care, 2001, 24, 1711-1721.
Goebel-Fabbri AE. Disturbed eating behaviours and eating disorders in type 1 diabetes: Clinical significance and treatment recommendations. Current Diabetes Reports, 2009, 9, 133-139.
McFarlane T., Polivy, J. & McCabe R.E. Help not harm: Psychological foundation for a non-dieting approach toward health. Journal of Social Issues, 1999, 55, (2), 261-276.
Olmsted, M.P., Colton, P.A., Daneman, D., Rydall, A.C. & Rodin, G.M. Prediction of the onset of disturbed eating behaviour in adolescent girls with type 1 diabetes. Diabetes Care, 2008, 31, 1978-1982.
Rodin, G.M., Olmsted, M.P., Rydall, A.C., Maharaj, S.I., Colton, P.A., Jones, J.M., Biancucci, L.A. & Daneman, D. Eating disorders in young women with type 1 diabetes mellitus. Journal of psychosomatic Research, 2002, 53, 943-949.
Striegel-Moore, R.H. and Bulik, C.M. Risk factors for eating disorders. American Psychologist, 2007, 62(3), 181-198.
^ McFarlane T., Polivy, J. & McCabe R.E. Help not harm: Psychological foundation for a non-dieting approach toward health. Journal of Social Issues, 1999, 55, (2), 261-276.
^ The DCCT Research Group: Influence of intensive diabetes treatment on body weight and composition of adults with Type 1 diabetes in the Diabetes Control and Complications Trial. Diabetes Care, 2001, 24, 1711-1721.