Eating disorders are, sadly, a fact of life among teenagers in the United States. According to the National Association of Anorexia Nervosa and Associated Disorders, more than half of all teenage girls and nearly one-third of teenage boys engage in unhealthy behaviors (skipping meals, vomiting, taking laxatives) to control their weight, and 1% of female adolescents have anorexia, characterized by an extremely distorted body image and emaciation. During this often difficult phase in life, having Type 1 diabetes presents unique challenges, as a study published last month in the journal Diabetes Care makes clear. While children and teens with diabetes may not be any more likely than other young people to engage in unhealthy behaviors, the shape that these behaviors take is often different.
The study, conducted at Oslo University Hospital in Norway, examined 770 young people between the ages of 11 and 19 who completed a survey called the Diabetes Eating Problem Survey–Revised (DEPS-R). Participants, divided roughly equally between males and females, had Type 1 diabetes for an average duration of 5.3 years; 56% used an insulin pump, and most of the others took at least four insulin injections each day. According to an article on the study at Medscape Medical News, the survey used in the study was developed to account for the unique situation that diabetes presents when it comes to evaluating eating behaviors. For example, among surveys designed to check for disturbed eating behavior in the general population, eating when not hungry and a preoccupation with food are considered suspect behaviors. Among people with diabetes, both of these behaviors are commonplace and not necessarily cause for alarm. The DEPS-R, on the other hand, asks questions about insulin restriction and other diabetes-specific behaviors.
Based on survey responses, 27.7% of females and 8.6% of males were identified as having disturbed eating behavior. Greater age and weight were both associated with a higher rate of disturbed behavior; only 7.2% of underweight participants and 8.1% of 11- to 13-year-olds earned this label, while 32.7% of obese participants and 38.1% of 17- to 19-year-olds did. Restricting or skipping insulin doses was found to be shockingly common: 31.6% of participants agreed with the statement, “When I overeat, I do not take enough insulin to cover the food,” while 6.9% agreed that, “After I overeat, I skip my next insulin dose.” Restricting or skipping insulin doses results in calories being “wasted” as glucose in the urine, a technique that can be as effective for weight control as it is dangerous, increasing the likelihood of both short-term emergencies like diabetic ketoacidosis and long-term diabetes complications. Not surprisingly, participants identified as having disturbed eating behavior had a higher average HbA1c level than other participants, at 9.2% versus 8.4%.
Addressing the issue of insulin restriction, in particular, may be very difficult for parents of teenagers with diabetes. Because of the obvious dangers that it poses, teens may be reluctant to admit that they ever engage in this behavior. But it may be tempting because it is so simple and effective: Calories simply disappear in the urine, without any of the unpleasant side effects of techniques, such as vomiting or using laxatives, that people without diabetes would need to use for a similar effect. And for young people, the prospect of an early death brought on by diabetes complications may seem distant and abstract compared with the social pressure they encounter to be thin, especially since they may already feel unpleasantly “different” because of their diabetes.
If you have Type 1 diabetes or are the parent of a child with diabetes, were you ever told about the dangers of eating disorders and insulin restriction? Have you ever restricted your insulin dose for the purpose of weight control? If so, why do you think you did this? Can anything be done to substantially reduce the incidence of disturbed eating behavior among young people with diabetes? Leave a comment below!