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Eating Disorders, Disordered Eating, and Insulin Omission in Type 1 Diabetic Adolescent Females: What’s all the fuss about? (Part 1 of a Series on ED)

January 17, 2010

For those of you out there who routinely care for adolescent females with or without diabetes this next series of posts is for you. We will move through the global nature of eating disorders, body image and females, disordered eating in adolescents, and disordered eating in special populations. I am beginning the series at a place where it should in theory end, because this topic is one of the most critical to anyone who cares for an adolescent female with Type 1 diabetes (T1DM). These girls who have T1DM and DEB begin in pediatrics and end up with adult endocrinology when their complications begin to surface. For those of you who don’t care for this population in a specialty area, your knowledge about this phenomenon is even more critical, because you care for them in other places. School nurses, pediatric clinic nurses, pediatric urgent care nurses, women’s health nurses, public health nurses, …. ANY nurse…. this post is for you.

Background. Let’s build from the basics, Type 1 Diabetes (T1DM) is an autoimmune disease, prevalent in 19 of every 100,000 Americans under the age of 20 (1), where there is insufficient insulin for metabolic function. Specifically, β-cell function in the pancreas ceases secondary to destruction by T-cell mediated responses (2). Many genetic and environmental triggers play roles in development of T1DM, with peak age of diagnosis between 10 to 14 years old (3).

The control of blood glucose levels in diabetes is important to prevent the onset of both short and long-term complications. The ADA recommends that, as a sign of control, Hemoglobin A1C levels (HbA1C) be monitored quarterly with a goal of 7% or less (2).  HbA1C levels, which correlate with average blood sugar readings over the previous 120 days, provide information about how well the medical regimen of the T1DM patient is working to control their blood glucose. Prolonged elevation of blood sugar levels leads to retinopathy, nephropathy, neuropathy, peripheral vascular, cardiovascular, and cerebrovascular disease (4,5).

Eating Disorders and Disordered Eating in Type 1 Diabetes. Eating disorders primarily affect young women and adolescents, being 3 times as high in lifetime prevalence among women than men (6). The mean age of onset of eating disorders ranges from 18 to 21, with some girls beginning as young as age 10 (6). Adolescent females with Type-1 diabetes have a two to four-fold higher incidence of eating disorders than their non-diabetic counterparts (7,8,9,10). More than just eating disorders, many girls engage in sub-clinical or disordered eating behavior (DEB). For diabetics, this becomes particularly problematic because their DEB of choice is insulin omission.

Insulin Omission. Insulin omission is a DEB weight loss method that is unique to adolescents with T1DM. Regardless of rates of actual eating disorders in general T1DM populations reported rates of insulin omission or dosage manipulation are high, between 14 to 73% (9, 10, 11, 12, 13, 14, 15, 16, 17, 18).

There is a significant risk for life threatening complications and mortality among DEB females with T1DM, where insulin omission is present (7, 19).  The majority of research in T1DM females supports elevated HA1C levels in the presence either of eating disorder, insulin omission, or both. Insulin omission results in increased rates of diabetic ketoacidosis, hospitalizations for acute illness, nephropathy, retinopathy, neuropathy and premature death (9, 12, 15, 18, 19, 20, 21, 22, 23).  Duration of insulin omission is the defining factor in rates and speed of development of nephropathy and retinopathy in T1DM females with eating disorders (17, 19). In essence, the girls with T1DM who omit insulin, regardless of eating disorder status, loose their eyes and kidneys at higher rates and more quickly than other T1DM adolescents with poor control.

Factors related to DEB in T1DM. There is a great deal of current research on factors related to DEB and prevalence rates. Factors strongly tied to DEB and insulin omission in T1DM adolescent females are: Body image (10, 21, 24, 25, 26, 29), elevated BMI (14, 21, 24), Depression (7, 17, 29), Self-esteem (21, 24), Feeling ineffective (25), Wishful thinking and emotional regulation (27), Diabetes management emotions (7, 28), Anxiety (7, 17), Negative family cohesion/communication (7, 17, 21), Maternal characteristics (14, 15, 26).

However, despite this mountain of research… no clinical guidelines for screening for this behavior, or even girls at risk for DEB and insulin omission, is non-existant. Further, no intervention research or recommendations have been made.

There is HOPE. Every good nurse knows that prevention is the key to any significant and costly illness. This is where we come in nurses. Now that we know the related factors, we can identify girls at risk for DEB in our practices and intervene on those factors. We can also look at simply screening for those who are high risk or engaging in this behavior in practice by two simple biological markers. It has been suggested that BMI and HgA1c level would be great biophysical screeners for this population (29). Further, RESEARCH on interventions and screening needs to be done, and who better to do that than nurses? The psychosocial, familial, and health care components of this complex phenomenon call for not only multidisciplinary research, but nursing to head such research teams. Are you ready to tackle this area nurses?

*Note: I am starting a pilot project to look at one intervention: Mothers and daughters, self-esteem, body image, and communication in high risk girls. Anyone want to join me?


1. National Institute Of Health. (2008, June ). National Diabetes Statistics, 2007. Retrieved August 11, 2009, from National Diabetes Information Clearinghouse Web site:

2. American Diabetes Association (2009). Executive Summary: Standards of medical care. Diabetes Care, 32(sup1), s6-s12. doi:10.2337/dc09-S006

3. Newhook, L., Curtis, J., Patterson, A., et al. (2004). High incidence of Type 1 Diabetes in the Avalon Peninsula, Newfoundland, Canada. Diabetes Care, 27(4), 885-888.

4. DCCT Writing Team (2003). Sustained effect of intensive treatment of type 1 diabetes mellitus on development and progression of diabetic nephropathy: the epidemiology of diabetes interventions and complications (EDIC) study. The Journal of the American Medical Association, 290(16), 2159-2167.

5. Martin, C., Albers, J., Waberski, B., et al. (2006). Neuropathy among the diabetes control and complications trial cohort 8 years after trial completion. Diabetes Care, 29(2), 340-344.

6. Hudson, J., Hiripi, E., Pope, H., & Kessler, R. (2007). The prevelance and correlates of eating disorders in the national comorbidity survey replication. Biological Psychiatry, 61, 348-358.

7. Goebel-fabbri, A., Fikkan, J., Frank, D., et al. (2008). Insulin restriction and associated morbidity and mortality in women with type 1 diabetes. Diabetes Care, 31(3), 415-419.

8. Jones, J., Lawsone, M., Daneman, D., et al. (2000). Eating disorders in adolescent females with and without type 1 diabetes: Cross sectional study. The British Medical Journal, 310(10), 1563-1566.

9. Nielsen, S. (2002). Eating disorders in females with type 1 diabetes: An update of a meta-analysis. European Eating Disorders in Review, 10(4), 241-254.

10. Pinar, R. (2005). Disordered eatingh behaviors among turkish adolescents with and without tyupe 1 diabetes. Journal of Pediatric Nursing, 20(5), 383-388.

11. Ackard, D., Neumark-Sztainer, D., Schmitz, K., et al. (2008). Disordered eating and body dissatisfaction in adolescents with type 1 diabetes and a population-based comparison sample: comparative prevalence and clinical implications. Pediatric Diabetes, 9(4 part-1), 312-319.

12. Crow , S., Keel, P., & Kendall, D. (1998). Eating disorders and insulin-dependent diabetes Mellitus. Psychometrics, 39(3), 233-243.

13. Daneman, D., Olmsted, M., & Ryall, A., et al., (1998). Eating disorders in young women with type 1 diabetes. Hormone Research, 50(sup1), 79-86.

14. Maharaj, S., Rodin, G., Olmsted, M., et al., (2003). Eating disturbances in girls with diabetes: the contribution of adolescent self-concept, maternal weight and shape concerns and mother-daughter relationships. Psychological Medicine, 33, 525-539.

15. Neumark-sztainer, D., Patterson, J., Mellin, A., et al., (2002). Weight control practices and disordered eating behaviors among adolescent females and males with type 1 diabetes. Diabetes Care, 25(8), 1289-1296.

16. Peveler, R., Bryden, K., Neil, A., et al., (2005). The relationship of disordered eating habits and attitudes to clinical outcomes in young adult females with type 1 diabetes. Diabetes Care, 28(1), 84-88

17. Takii, M., Komaki, G., Ugchigata, Y., et al.,  (1999). Differences between bulimia nervosa and binge-eating disorder in females with type 1 diabetes: The important role of insulin omission. Journal of Psychosomatic research, 47(3), 221-231.

18. Takii, M., Uchigata, Y., Nozaki, T., et al.,  (2002). Classification of type 1 diabetic females with bulimia nervosa into subgroups according to purging behavior. Diabetes Care, 25(9), 1571-1575.

19. Takii, M., Uchigata, Y., Tokunaga, S., et al., (2008). The duration of severe insulin omission is the factor most closely associated with the microvascular complications of type 1 diabetic females with eating disorders. International Journal of Eating Disorders, 41(3), 259-264.

20. Bryden, K., Neil, A., Mayou, R., et al., (1999). Eating habits, body weight, and insulin misuse. Diabetes Care, 22(12), 1956-1960.

21. Colton, P., Olmsted, M., Daneman, D., Ryadall, A., & Rodin, G. (2007). Natural history and predictors of disturbed eating behavior in girls with type 1 diabetes. Diabetic Medicine, 24, 424-429.

22. Goebel-fabbri, A., Fikkan, J., Frank, D., et al.,  (2008). Insulin restriction and associated morbidity and mortality in women with type 1 diabetes. Diabetes Care, 31(3), 415-419.

23. Nielsen, S., Emboerg, C., & Molback, A. (2002). Mortality in concurrent type 1 diabetes and anorexia nervosa. Diabetes Care, 25(2), 309-312.

24. Engstrom, I., Kroon, M., Arvidsson, C., et al. (1999). Eating disorders in adolescent girls with insulin-dependent diabetes mellitus: A population-based case-control study. Acta Paediatrics, 88, 175-180.

25. Kahn, Y., & Montgomery, A. (1996). Eating attitudes in young females with diabetes: Insulin omission identifies a vulnerable subgroup. The British Journal of Medical PSychology, 69, 343-353.

26. Kitchler, J., Foster, C., & Opipari-arrigan, L. (2008). The relationship between nebative communication and body image dissatsifaction in adolescent females with type 1 diabetes mellitus. Journal of Health Psychology, 13, 336-347.

27. Grylli, V., Wagner, G., Hafferl-Gattermayer, A., et al., (2005). Disturbing eating attitudes, coping styles, and subjective quality of life in adolescents with Type 1 diabetes. Journal of Psychosomatic Research, 59, 65-72.

28. Affiento, S., Backstrand, J., Lammi-Keefe, C., et al.,  (1997). Subclinical and clinical eating disorders in IDDM negatively affect metabolic control. Diabetes Care, 20(2), 182-184.

29. Olmsted, M., Colton, P., Daneman, D., Rydall, A., & Rodin, G. (2008). Predictions of the onset of disturbed eating behavior in adolescent girls with type 1 diabetes. Diabets Care, 31(10), 1978-1982.


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